Provider Demographics
NPI:1316621634
Name:MICELI, RENAMARIE MIRACLE
Entity type:Individual
Prefix:
First Name:RENAMARIE
Middle Name:MIRACLE
Last Name:MICELI
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 1:726 E GOLF RD APT F
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-4930
Mailing Address - Country:US
Mailing Address - Phone:847-521-9125
Mailing Address - Fax:
Practice Address - Street 1:3030 W SALT CREEK LN STE 350
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-5000
Practice Address - Country:US
Practice Address - Phone:877-486-4140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician