Provider Demographics
NPI:1851514699
Name:OWEN-MIRACLE, REGINA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:
Last Name:OWEN-MIRACLE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 CUMBERLAND DR
Mailing Address - Street 2:
Mailing Address - City:HARROGATE
Mailing Address - State:TN
Mailing Address - Zip Code:37752-6939
Mailing Address - Country:US
Mailing Address - Phone:423-869-3250
Mailing Address - Fax:423-869-0595
Practice Address - Street 1:390 CUMBERLAND DR
Practice Address - Street 2:
Practice Address - City:HARROGATE
Practice Address - State:TN
Practice Address - Zip Code:37752-6939
Practice Address - Country:US
Practice Address - Phone:423-869-3250
Practice Address - Fax:423-869-0595
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA00605225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant