Provider Demographics
NPI:1184143927
Name:MIRACLE, BRIDGETT LOREN
Entity type:Individual
Prefix:
First Name:BRIDGETT
Middle Name:LOREN
Last Name:MIRACLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 MILL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-4182
Mailing Address - Country:US
Mailing Address - Phone:606-677-1166
Mailing Address - Fax:606-677-0693
Practice Address - Street 1:303 SECOND ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-2390
Practice Address - Country:US
Practice Address - Phone:606-677-1166
Practice Address - Fax:606-677-0693
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY174748225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty