Provider Demographics
NPI:1407203920
Name:DOUGLAS, MIRACLE A (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MIRACLE
Middle Name:A
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MIRACLE
Other - Middle Name:ASHLEY-ANNGELLE
Other - Last Name:ANDERSON-DOUGLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:1553 ROLLING MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-9215
Mailing Address - Country:US
Mailing Address - Phone:470-710-9221
Mailing Address - Fax:
Practice Address - Street 1:1553 ROLLING MEADOWS DR
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-9215
Practice Address - Country:US
Practice Address - Phone:470-710-9221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT31362225100000X
GAPT0149612251P0200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics