Provider Demographics
NPI:1063032712
Name:MILLER, MICHELLE L (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:L
Last Name:MILLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1645 W JACKSON BLVD STE 400
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3244
Practice Address - Country:US
Practice Address - Phone:312-942-8258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-23
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.010247103TC0700X
IN20043420A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical