Provider Demographics
NPI:1093953473
Name:MILLER, SHA'MEL CARRISSA (OTA)
Entity Type:Individual
Prefix:MISS
First Name:SHA'MEL
Middle Name:CARRISSA
Last Name:MILLER
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2539 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-2228
Mailing Address - Country:US
Mailing Address - Phone:518-331-4695
Mailing Address - Fax:
Practice Address - Street 1:1 RAPP RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-4491
Practice Address - Country:US
Practice Address - Phone:518-867-3061
Practice Address - Fax:518-867-3066
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007210-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant