Provider Demographics
NPI:1003212804
Name:MILLER, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:MILLER
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 1:12501 CAPTAINS BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-1607
Mailing Address - Country:US
Mailing Address - Phone:502-767-2164
Mailing Address - Fax:317-858-8715
Practice Address - Street 1:6317 HIGHWAY 329
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:KY
Practice Address - Zip Code:40014-9040
Practice Address - Country:US
Practice Address - Phone:502-384-0910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-06
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005770A225X00000X
KY134115225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist