Provider Demographics
NPI:1790223394
Name:MIRACLE CITY, LLC
Entity Type:Organization
Organization Name:MIRACLE CITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:914-222-4156
Mailing Address - Street 1:2800 BRUCKNER BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10465-1972
Mailing Address - Country:US
Mailing Address - Phone:914-222-4156
Mailing Address - Fax:320-205-4576
Practice Address - Street 1:2800 BRUCKNER BLVD STE 205
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10465-1972
Practice Address - Country:US
Practice Address - Phone:914-222-4156
Practice Address - Fax:320-205-4576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-03
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251S00000X, 385H00000X, 251S00000X
NYCRPA-P-2061175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite Care
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty