Provider Demographics
NPI:1477579290
Name:MIRACLE, LOUISE E (PHD, HSPP, INC)
Entity Type:Individual
Prefix:DR
First Name:LOUISE
Middle Name:E
Last Name:MIRACLE
Suffix:
Gender:F
Credentials:PHD, HSPP, INC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 3155
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402
Mailing Address - Country:US
Mailing Address - Phone:812-339-4877
Mailing Address - Fax:812-339-4877
Practice Address - Street 1:2525 W. VERNAL PIKE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404
Practice Address - Country:US
Practice Address - Phone:812-339-4877
Practice Address - Fax:812-339-4877
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040642A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist