Provider Demographics
NPI:1629035415
Name:MIRACLE OF SPEECH REHAB, INC.
Entity Type:Organization
Organization Name:MIRACLE OF SPEECH REHAB, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC/SLP
Authorized Official - Phone:479-963-2005
Mailing Address - Street 1:401 N EXPRESS ST
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:AR
Mailing Address - Zip Code:72855-2354
Mailing Address - Country:US
Mailing Address - Phone:479-963-2005
Mailing Address - Fax:479-963-2005
Practice Address - Street 1:401 N EXPRESS ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:AR
Practice Address - Zip Code:72855-2354
Practice Address - Country:US
Practice Address - Phone:479-963-2005
Practice Address - Fax:479-963-2005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1158235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5T663Medicare UPIN