Provider Demographics
NPI:1730832502
Name:MIRACLE MENTAL HEALTH PLLC
Entity type:Organization
Organization Name:MIRACLE MENTAL HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CORDELIA
Authorized Official - Middle Name:OGECHI
Authorized Official - Last Name:EGWIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-753-8895
Mailing Address - Street 1:4830 WILSON RD STE 300
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77396-1972
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4830 WILSON RD STE 300
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77396-1972
Practice Address - Country:US
Practice Address - Phone:888-753-8895
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-01
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty