Provider Demographics
NPI:1902378037
Name:MIRACLE KIDS SUCCESS ACADEMY NORTH
Entity Type:Organization
Organization Name:MIRACLE KIDS SUCCESS ACADEMY NORTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-761-6680
Mailing Address - Street 1:806 GLENDALE ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4455
Mailing Address - Country:US
Mailing Address - Phone:870-932-3600
Mailing Address - Fax:
Practice Address - Street 1:806 GLENDALE ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4455
Practice Address - Country:US
Practice Address - Phone:870-932-3600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIRACLE KIDS SUCCESS ACADEMY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-31
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty