Provider Demographics
NPI:1275394371
Name:MIRACLE, NICOLE ALEXANDRIA (CDCA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ALEXANDRIA
Last Name:MIRACLE
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 E HELENA ST APT G
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-4210
Mailing Address - Country:US
Mailing Address - Phone:937-794-2844
Mailing Address - Fax:
Practice Address - Street 1:1087 W 2ND ST
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-3713
Practice Address - Country:US
Practice Address - Phone:937-708-8053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH186560101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)