Provider Demographics
NPI:1326489253
Name:MILLER, SALLIE CAROLINE (PTA)
Entity Type:Individual
Prefix:
First Name:SALLIE
Middle Name:CAROLINE
Last Name:MILLER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 S 23RD ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-7541
Mailing Address - Country:US
Mailing Address - Phone:618-960-6904
Mailing Address - Fax:
Practice Address - Street 1:12801 N CENTRAL EXPY
Practice Address - Street 2:SUITE 1750
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-1716
Practice Address - Country:US
Practice Address - Phone:877-293-6287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160002755225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant