Provider Demographics
NPI:1477991560
Name:MINI MIRACLES PEDIATRIC THERAPY, PLLC
Entity Type:Organization
Organization Name:MINI MIRACLES PEDIATRIC THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-624-1237
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37605-0191
Mailing Address - Country:US
Mailing Address - Phone:423-534-8897
Mailing Address - Fax:423-328-8662
Practice Address - Street 1:2214 E FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-2860
Practice Address - Country:US
Practice Address - Phone:423-928-6464
Practice Address - Fax:423-232-7970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-11
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119003962251C00000X
VA4611252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1477991560Medicaid