Provider Demographics
NPI:1669100988
Name:ROGERS-CAMPBELL, MIRACLE LASHANIECE
Entity type:Individual
Prefix:
First Name:MIRACLE
Middle Name:LASHANIECE
Last Name:ROGERS-CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 JAYCEE CT APT 108
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6505
Mailing Address - Country:US
Mailing Address - Phone:651-703-1258
Mailing Address - Fax:
Practice Address - Street 1:1720 BASSETT DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6569
Practice Address - Country:US
Practice Address - Phone:507-565-0150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-14
Last Update Date:2022-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN10719725Medicaid