Provider Demographics
NPI:1639356223
Name:MIRACLE, CHERYL (LCSW)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:MIRACLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3563 S STATE ROAD 13
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-9162
Mailing Address - Country:US
Mailing Address - Phone:260-563-8453
Mailing Address - Fax:
Practice Address - Street 1:3409 S 200 W
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-9613
Practice Address - Country:US
Practice Address - Phone:260-563-8453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-25
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005876A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000671582OtherBLUE CROSS BLUE SHIELD
IN9478593OtherAETNA
IN600642605OtherMAGELLAN
IN201097990Medicaid
IN000542210OtherUNITED BEHAVIORAL HEALTH
IN1639356223Medicare PIN