Provider Demographics
NPI:1639814627
Name:MIRACLES BEHAVIOR THERAPY CORP
Entity Type:Organization
Organization Name:MIRACLES BEHAVIOR THERAPY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARLON
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-250-7352
Mailing Address - Street 1:9160 FORUM CORPORATE PKWY STE 350
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-7808
Mailing Address - Country:US
Mailing Address - Phone:786-557-0300
Mailing Address - Fax:
Practice Address - Street 1:9160 FORUM CORPORATE PKWY STE 350
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7808
Practice Address - Country:US
Practice Address - Phone:786-557-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty