Provider Demographics
NPI:1689921397
Name:MIRACLE, MATTHEW TAYLOR (BA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:TAYLOR
Last Name:MIRACLE
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:76 CHURCH ST STE 301
Mailing Address - Street 2:
Mailing Address - City:WHITINSVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:01588-1464
Mailing Address - Country:US
Mailing Address - Phone:508-234-4181
Mailing Address - Fax:508-234-3944
Practice Address - Street 1:80 WORCESTER ST
Practice Address - Street 2:
Practice Address - City:NORTH GRAFTON
Practice Address - State:MA
Practice Address - Zip Code:01536-1041
Practice Address - Country:US
Practice Address - Phone:774-293-1116
Practice Address - Fax:774-389-0308
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA12165101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health