Provider Demographics
NPI:1689373391
Name:HALL, MIRACLE
Entity Type:Individual
Prefix:
First Name:MIRACLE
Middle Name:
Last Name:HALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2624 N DIVISION ST # 1091
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-2129
Mailing Address - Country:US
Mailing Address - Phone:509-542-7763
Mailing Address - Fax:
Practice Address - Street 1:2624 N DIVISION ST # 1091
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-2129
Practice Address - Country:US
Practice Address - Phone:509-542-7763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-01
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC614082481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical