Provider Demographics
NPI:1750430252
Name:MIRACLE, SANDRA J (PT)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:J
Last Name:MIRACLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10505 19TH AVE SE
Mailing Address - Street 2:SUITE B
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-4280
Mailing Address - Country:US
Mailing Address - Phone:408-570-0510
Mailing Address - Fax:408-945-4011
Practice Address - Street 1:111 S 12TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4000
Practice Address - Country:US
Practice Address - Phone:360-419-9300
Practice Address - Fax:360-419-9301
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007782225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA125415OtherDEPT OF LABOR & INDUSTRIE
WA8341885Medicaid
AB09677Medicare ID - Type Unspecified
S80919Medicare UPIN