Provider Demographics
NPI:1306362264
Name:MILLER, DINAH JO
Entity Type:Individual
Prefix:
First Name:DINAH
Middle Name:JO
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 1:3535 ALAN DR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-5211
Mailing Address - Country:US
Mailing Address - Phone:321-543-2548
Mailing Address - Fax:
Practice Address - Street 1:1071 PORT MALABAR BLVD., NE
Practice Address - Street 2:11 E
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32905-5161
Practice Address - Country:US
Practice Address - Phone:407-720-8887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-22
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL201447261Medicaid