Provider Demographics
NPI:1215599725
Name:MILLER, MICHAEL JOHNATHAN
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHNATHAN
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 ADAMS ST NE APT E28
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-8027
Mailing Address - Country:US
Mailing Address - Phone:772-971-8230
Mailing Address - Fax:
Practice Address - Street 1:3131 ADAMS ST NE APT E28
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-8027
Practice Address - Country:US
Practice Address - Phone:772-971-8230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0TA.0000858225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM3808OtherCOTA