Provider Demographics
NPI:1326732769
Name:MILLER, LAURISSA J
Entity Type:Individual
Prefix:
First Name:LAURISSA
Middle Name:J
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURISSA
Other - Middle Name:J
Other - Last Name:DAVID
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 PASEO CAMARILLO STE 221
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-0788
Mailing Address - Country:US
Mailing Address - Phone:805-233-0058
Mailing Address - Fax:
Practice Address - Street 1:1000 PASEO CAMARILLO STE 221
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-0788
Practice Address - Country:US
Practice Address - Phone:805-233-0058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1148951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical