Provider Demographics
NPI:1366927352
Name:BUCKLEY, MIRACLE (OTR)
Entity type:Individual
Prefix:
First Name:MIRACLE
Middle Name:
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 ARBOR DR APT 1362
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4856
Mailing Address - Country:US
Mailing Address - Phone:601-454-3322
Mailing Address - Fax:
Practice Address - Street 1:380 HENRY ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-6048
Practice Address - Country:US
Practice Address - Phone:718-855-6789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-26
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty