Provider Demographics
NPI:1033941737
Name:MIRACLE, MARISA BROOKE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:BROOKE
Last Name:MIRACLE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 LOVERS LN
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:TX
Mailing Address - Zip Code:76450-4356
Mailing Address - Country:US
Mailing Address - Phone:940-521-6045
Mailing Address - Fax:
Practice Address - Street 1:442 OAK ST
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:TX
Practice Address - Zip Code:76450-2522
Practice Address - Country:US
Practice Address - Phone:940-247-0402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120966235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist