Provider Demographics
NPI:1316215742
Name:LAURENCE MILLER PHD PA
Entity Type:Organization
Organization Name:LAURENCE MILLER PHD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:561-392-8881
Mailing Address - Street 1:399 CAMINO GARDENS BLVD
Mailing Address - Street 2:SUITE101
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-5828
Mailing Address - Country:US
Mailing Address - Phone:561-392-8881
Mailing Address - Fax:
Practice Address - Street 1:399 CAMINO GARDENS BLVD
Practice Address - Street 2:SUITE101
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-5828
Practice Address - Country:US
Practice Address - Phone:561-392-8881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4413103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73704Medicare UPIN