Provider Demographics
NPI:1790092211
Name:MIRACLES SUPPORTIVE SERVICES
Entity Type:Organization
Organization Name:MIRACLES SUPPORTIVE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNISCIA
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:SHERROD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-827-7577
Mailing Address - Street 1:1305 W HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:TARBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27886-4119
Mailing Address - Country:US
Mailing Address - Phone:252-827-7577
Mailing Address - Fax:
Practice Address - Street 1:1305 W HOWARD AVE
Practice Address - Street 2:
Practice Address - City:TARBORO
Practice Address - State:NC
Practice Address - Zip Code:27886-4119
Practice Address - Country:US
Practice Address - Phone:252-827-7577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-03
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty