Provider Demographics
NPI:1982717385
Name:MIRACLE, WAYNE (EDD HSPP)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:
Last Name:MIRACLE
Suffix:
Gender:M
Credentials:EDD HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 S. LIBERTY ST.
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47305-2341
Mailing Address - Country:US
Mailing Address - Phone:765-288-8586
Mailing Address - Fax:
Practice Address - Street 1:413 S. LIBERTY ST.
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47305-2341
Practice Address - Country:US
Practice Address - Phone:765-288-8586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100333760Medicaid
IN000000186190OtherANTHEM BCBS
IN112439000OtherMAGELLAN
IN945500CMedicare ID - Type Unspecified
IN000000186190OtherANTHEM BCBS