Provider Demographics
NPI:1346265485
Name:MILLER, COLLEEN A
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:A
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5733 E LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CAZENOVIA
Mailing Address - State:NY
Mailing Address - Zip Code:13035-9324
Mailing Address - Country:US
Mailing Address - Phone:315-655-2740
Mailing Address - Fax:
Practice Address - Street 1:138 N COURT ST.
Practice Address - Street 2:VETERANS MEMORIAL BUILDING
Practice Address - City:WAMPSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13163-0608
Practice Address - Country:US
Practice Address - Phone:315-366-2327
Practice Address - Fax:315-366-2599
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR050997-1101YM0800X
NYRO50997-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBB3993Medicare PIN