Provider Demographics
NPI:1730586173
Name:MITCHELL, MIRACLE (LPC)
Entity type:Individual
Prefix:
First Name:MIRACLE
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 GRANITE WAY
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-6952
Mailing Address - Country:US
Mailing Address - Phone:601-826-9947
Mailing Address - Fax:
Practice Address - Street 1:805 N BEECH ST STE 2
Practice Address - Street 2:
Practice Address - City:TALLULAH
Practice Address - State:LA
Practice Address - Zip Code:71282-3809
Practice Address - Country:US
Practice Address - Phone:318-493-5147
Practice Address - Fax:318-493-5148
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-01
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1951101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08532364Medicaid