Provider Demographics
NPI:1083771059
Name:MILLER, TINA (MA, CCC, SLP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:MA, CCC, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 BROOKCREST CIR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4749
Mailing Address - Country:US
Mailing Address - Phone:321-636-9796
Mailing Address - Fax:
Practice Address - Street 1:332 BROOKCREST CIR
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-4749
Practice Address - Country:US
Practice Address - Phone:321-636-9796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA2960235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL882247600Medicaid