Provider Demographics
NPI:1275002735
Name:MILLER, MICHELLE LYN
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYN
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 1:14122 IVANHOE DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-3888
Mailing Address - Country:US
Mailing Address - Phone:586-615-4346
Mailing Address - Fax:
Practice Address - Street 1:3601 E 11 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-2878
Practice Address - Country:US
Practice Address - Phone:855-824-5669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician