Provider Demographics
NPI:1376109892
Name:MIRACLE, KADIAN SAMANTHA
Entity Type:Individual
Prefix:
First Name:KADIAN
Middle Name:SAMANTHA
Last Name:MIRACLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5806 WARNER MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-8694
Mailing Address - Country:US
Mailing Address - Phone:740-274-5792
Mailing Address - Fax:
Practice Address - Street 1:100 WEST COLLEGE STREET
Practice Address - Street 2:WHISLER HALL
Practice Address - City:GRANVILLE
Practice Address - State:OH
Practice Address - Zip Code:43023
Practice Address - Country:US
Practice Address - Phone:740-274-5792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-10
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.7565103TC0700X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service