Basic Information
| Provider Information | |||||||||
| NPI: | 1184945701 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIRACLE KIDS SUCCESS ACADEMY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 STILLWATER DR | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724049119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709322600 | ||||||||
| FaxNumber: | 8709323611 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 STILLWATER DR | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724049119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709322600 | ||||||||
| FaxNumber: | 8709323611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2010 | ||||||||
| LastUpdateDate: | 11/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | DECKER | ||||||||
| AuthorizedOfficialFirstName: | SHELLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8709322600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 235Z00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 181713742 | 05 | AR | MEDICAID |