Provider Demographics
NPI:1316593205
Name:MILLER, CHARISSE
Entity Type:Individual
Prefix:
First Name:CHARISSE
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHARISSE
Other - Middle Name:
Other - Last Name:MARCHANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11715 S STATE ST APT J103
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-6935
Mailing Address - Country:US
Mailing Address - Phone:801-889-0265
Mailing Address - Fax:
Practice Address - Street 1:11715 S STATE ST APT J103
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-6935
Practice Address - Country:US
Practice Address - Phone:801-889-0265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT801998991OtherSELECT HEALTH