Provider Demographics
NPI:1215121694
Name:MIRACLE, SHAWN DENEE (LMSW)
Entity type:Individual
Prefix:MS
First Name:SHAWN
Middle Name:DENEE
Last Name:MIRACLE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33800 GRAND TRAVERSE ST
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48186-4675
Mailing Address - Country:US
Mailing Address - Phone:734-728-2423
Mailing Address - Fax:734-728-2183
Practice Address - Street 1:33800 GRAND TRAVERSE ST
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-4675
Practice Address - Country:US
Practice Address - Phone:734-728-2423
Practice Address - Fax:734-728-2183
Is Sole Proprietor?:No
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010803431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical