Provider Demographics
NPI:1225327943
Name:MILLERWISE, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:MILLERWISE
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 1:4221 10TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-5935
Mailing Address - Country:US
Mailing Address - Phone:269-998-0704
Mailing Address - Fax:
Practice Address - Street 1:6951 PISTOL RANGE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33635-9601
Practice Address - Country:US
Practice Address - Phone:813-814-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-04
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
1-11-8928103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist