Provider Demographics
NPI:1306375902
Name:MILLER, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 W 500 S STE 9
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-2912
Mailing Address - Country:US
Mailing Address - Phone:435-789-6300
Mailing Address - Fax:435-725-6325
Practice Address - Street 1:1140 W 500 S STE 9
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2912
Practice Address - Country:US
Practice Address - Phone:435-789-6300
Practice Address - Fax:435-725-6325
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
UT171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health