Provider Demographics
NPI:1326451576
Name:MILLER, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARTY
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1101 W HIBISCUS BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-2718
Mailing Address - Country:US
Mailing Address - Phone:321-723-0070
Mailing Address - Fax:321-723-6150
Practice Address - Street 1:1101 W HIBISCUS BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2718
Practice Address - Country:US
Practice Address - Phone:321-723-0070
Practice Address - Fax:321-723-6150
Is Sole Proprietor?:No
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH1556101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health