Provider Demographics
NPI:1194020503
Name:MILLER, SARA MONTAGUE (MS)
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:MONTAGUE
Last Name:MILLER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MISS
Other - First Name:SARA
Other - Middle Name:AMES
Other - Last Name:MONTAGUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2112 BIENVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3052
Mailing Address - Country:US
Mailing Address - Phone:228-875-1590
Mailing Address - Fax:228-875-1591
Practice Address - Street 1:2112 BIENVILLE BLVD STE M2
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3027
Practice Address - Country:US
Practice Address - Phone:228-215-0825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-14
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1728101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018214Medicaid