Basic Information
| Provider Information | |||||||||
| NPI: | 1568799658 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIRACLE KIDS SUCCESS ACADEMY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 STILLWATER DR | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724049119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709323600 | ||||||||
| FaxNumber: | 8709323611 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 STILLWATER DR | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724049119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709323600 | ||||||||
| FaxNumber: | 8709323611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2009 | ||||||||
| LastUpdateDate: | 11/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | KELLER | ||||||||
| AuthorizedOfficialFirstName: | SHELLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8709323600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MCD, CCC-SLP | ||||||||
| NPICertificationDate: | 11/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD1600X | N | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 179889724 | 05 | AR | MEDICAID |