| Doctor Name: | MALLORY MIRACLE |
| NPI Number: | 1538507413 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | 12-043 |
| Business Practice Address: | 6317 Highway 329 Crestwood, KY - 400149040 |
| Business Phone Number: | 5023840910 |
| Business Fax Number: | 5023840908 |
| Mailing Address: | 4529 Biles Ct, LOUISVILLE |
| State: | KY |
| Postal Code: | 402413703 |
| Phone Number: | 8168303840 |
| Fax Number: | |
| NPI Enumeration Date: | 06/12/2013 |
| NPI Last Update Date: | 06/12/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 235Z00000X |
| License Number: | 12-043 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | KY |
| Taxonomy Type: | Speech, Language and Hearing Service Providers |
| Taxonomy Classification: | Speech-Language Pathologist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A speech pathologist is a person qualified by a master |