Provider Demographics
NPI:1114257615
Name:MILLER, LAURA DALE
Entity Type:Individual
Prefix:MISS
First Name:LAURA
Middle Name:DALE
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 1:111 GAIL DR
Mailing Address - Street 2:
Mailing Address - City:EDMONTON
Mailing Address - State:KY
Mailing Address - Zip Code:42129-9300
Mailing Address - Country:US
Mailing Address - Phone:270-590-6958
Mailing Address - Fax:844-688-4227
Practice Address - Street 1:111 GAIL DR
Practice Address - Street 2:
Practice Address - City:EDMONTON
Practice Address - State:KY
Practice Address - Zip Code:42129
Practice Address - Country:US
Practice Address - Phone:270-590-6958
Practice Address - Fax:844-688-4227
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-05
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY201103230222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist