Provider Demographics
NPI:1053850172
Name:MILLER, S. MARILYN
Entity Type:Individual
Prefix:
First Name:S. MARILYN
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 1:90 FAIRLIE ST NW
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-2127
Mailing Address - Country:US
Mailing Address - Phone:912-665-3759
Mailing Address - Fax:
Practice Address - Street 1:90 FAIRLIE ST NW
Practice Address - Street 2:SUITE 203
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-2127
Practice Address - Country:US
Practice Address - Phone:912-665-3759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2987103G00000X
TX33123103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist