Provider Demographics
NPI:1568044147
Name:MIRACLE-BOTLEY, PATRICIA
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:MIRACLE-BOTLEY
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 1:83 HARDING AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLYN
Mailing Address - State:NJ
Mailing Address - Zip Code:08107-1530
Mailing Address - Country:US
Mailing Address - Phone:856-631-8102
Mailing Address - Fax:
Practice Address - Street 1:500 S BURNT MILL RD
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-2205
Practice Address - Country:US
Practice Address - Phone:888-859-7749
Practice Address - Fax:888-859-7749
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-21-49409103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty