Provider Demographics
NPI:1578565909
Name:MIRACLE, CHYRL ANN (OT)
Entity Type:Individual
Prefix:MRS
First Name:CHYRL
Middle Name:ANN
Last Name:MIRACLE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 DUNCAN ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37821-2016
Mailing Address - Country:US
Mailing Address - Phone:426-625-9785
Mailing Address - Fax:
Practice Address - Street 1:123 WESTERN PLAZA WAY
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:TN
Practice Address - Zip Code:37821-2215
Practice Address - Country:US
Practice Address - Phone:423-623-7777
Practice Address - Fax:423-623-0707
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOT928225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4020256OtherBCBS PROVIDER NUMBER
TN3655456Medicaid
TN3655456Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER