Provider Demographics
NPI:1316470263
Name:JANUARY, MIRACLE
Entity type:Individual
Prefix:
First Name:MIRACLE
Middle Name:
Last Name:JANUARY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRACLE
Other - Middle Name:
Other - Last Name:MCLEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16461 CEDAR VIEW LN
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-4740
Mailing Address - Country:US
Mailing Address - Phone:323-408-1813
Mailing Address - Fax:
Practice Address - Street 1:3281 E GUASTI RD STE 440
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-7635
Practice Address - Country:US
Practice Address - Phone:909-323-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91868106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist