Provider Demographics
NPI:1164629259
Name:MILLER, THERESA R (PTA)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:R
Last Name:MILLER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 S 550 E
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:IN
Mailing Address - Zip Code:47558-5497
Mailing Address - Country:US
Mailing Address - Phone:812-486-2561
Mailing Address - Fax:
Practice Address - Street 1:2119 E NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IN
Practice Address - Zip Code:47501-4507
Practice Address - Country:US
Practice Address - Phone:812-254-3301
Practice Address - Fax:812-257-0039
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002663A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant