1487575130 NPI number — MIRACLE KIDS SUCCESS ACADEMY, INC.

Table of content: SARVENAZ MOSHFEGH ASIEDU LMHC (NPI 1164973384)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487575130 NPI number — MIRACLE KIDS SUCCESS ACADEMY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIRACLE KIDS SUCCESS ACADEMY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487575130
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 STILLWATER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72404-9119
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-932-3600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 STILLWATER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72404-9119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-932-3600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/21/2026

Additional Information

Authorized Official

Authorized Official Last Name:
KELLER
Authorized Official First Name:
SHELLY
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
870-932-3600

Provider Taxonomy Codes

  • Taxonomy code: 103TC2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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