Provider Demographics
NPI:1629229323
Name:LOUISE MIRACLE, PHD, HSPP, INC.
Entity Type:Organization
Organization Name:LOUISE MIRACLE, PHD, HSPP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LOUISE
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRACLE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, HSPP
Authorized Official - Phone:812-339-4877
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040642A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty