NPIMap

Organization Active NPI

Miracle Kids Success Academy, Inc.

  • Rehabilitation Clinic/Center
  • Jonesboro, AR
National Provider Identifier
1568799658
Registry record updated Nov 30, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rehabilitation Clinic/CenterTaxonomy code 261QR0400X
Legal business name
MIRACLE KIDS SUCCESS ACADEMY, INC.
Practice address
1900 Stillwater Dr
Jonesboro, AR 72404-9119
Phone
(870) 932-3600
Fax
(870) 932-3611
NPI assigned
Nov 10, 2009
Last updated
Nov 30, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 30, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Shelly Keller, MCD, CCC-SLPNPI 1629008321
Title
Owner/President
Phone
(870) 932-3600

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Developmental Disabilities Clinic/Center 261QD1600X
Adolescent and Children Mental Health Clinic/Center 261QM0855X
Rehabilitation Clinic/Center 261QR0400X Primary

Addresses

Primary practice location

1900 Stillwater Dr
Jonesboro, AR 72404-9119

Mailing address

1900 Stillwater Dr
Jonesboro, AR 72404-9119
Phone (870) 932-3600

Other identifiers 1

IdentifierTypeStateIssuer
179889724MedicaidAR

National Provider Directory

National Provider Directory
Tax ID family
Miracle Kids Success Academy6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1257811200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1606694400000",
    "number": "1568799658",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1900 STILLWATER DR",
            "city": "JONESBORO",
            "state": "AR",
            "postal_code": "724049119",
            "telephone_number": "870-932-3600",
            "fax_number": "870-932-3611"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1900 STILLWATER DR",
            "city": "JONESBORO",
            "state": "AR",
            "postal_code": "724049119",
            "telephone_number": "870-932-3600",
            "fax_number": "870-932-3611"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MIRACLE KIDS SUCCESS ACADEMY, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-11-10",
        "last_updated": "2020-11-30",
        "certification_date": "2020-11-30",
        "status": "A",
        "authorized_official_last_name": "KELLER",
        "authorized_official_first_name": "SHELLY",
        "authorized_official_title_or_position": "OWNER/PRESIDENT",
        "authorized_official_telephone_number": "870-932-3600",
        "authorized_official_credential": "MCD, CCC-SLP"
    },
    "taxonomies": [
        {
            "code": "261QD1600X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Developmental Disabilities",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0855X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adolescent and Children Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rehabilitation",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "179889724",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Jonesboro, AR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 30, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.