Provider Demographics
NPI:1275514945
Name:MARY L MILLER, M.A., P.A.
Entity Type:Organization
Organization Name:MARY L MILLER, M.A., P.A.
Other - Org Name:MARTY MILLER, M.A., P.A.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-723-0070
Mailing Address - Street 1:PO BOX 1176
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32902-1176
Mailing Address - Country:US
Mailing Address - Phone:321-723-0070
Mailing Address - Fax:321-723-6150
Practice Address - Street 1:1101 W HIBISCUS BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2718
Practice Address - Country:US
Practice Address - Phone:321-723-0070
Practice Address - Fax:321-723-6150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH1556101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty