Provider Demographics
NPI:1225620800
Name:MILLER, BETTINA
Entity Type:Individual
Prefix:
First Name:BETTINA
Middle Name:
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 1:2240 MELBOURNE AVE APT 1509
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MI
Mailing Address - Zip Code:48130-1597
Mailing Address - Country:US
Mailing Address - Phone:151-793-7979
Mailing Address - Fax:
Practice Address - Street 1:6530 SECOR RD STE 10
Practice Address - Street 2:
Practice Address - City:LAMBERTVILLE
Practice Address - State:MI
Practice Address - Zip Code:48144-9456
Practice Address - Country:US
Practice Address - Phone:419-260-3637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013399101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor