Provider Demographics
NPI:1295030609
Name:MILLER, LISA MARIE (MSED, BCBA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:MILLER
Suffix:
Gender:F
Credentials:MSED, BCBA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:WIMBERLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 901863
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64190-1863
Mailing Address - Country:US
Mailing Address - Phone:913-522-4775
Mailing Address - Fax:816-326-0835
Practice Address - Street 1:6675 NW MEYERS CIR
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MO
Practice Address - Zip Code:64152-5220
Practice Address - Country:US
Practice Address - Phone:913-522-4775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-14
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010042683103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst