Provider Demographics
NPI:1043970643
Name:MILLER, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
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 1:207 MAIN AVE W
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-1725
Mailing Address - Country:US
Mailing Address - Phone:701-499-1022
Mailing Address - Fax:
Practice Address - Street 1:207 MAIN AVE W
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-1725
Practice Address - Country:US
Practice Address - Phone:701-499-1022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-22
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician