Provider Demographics
NPI:1376198390
Name:MILLER, SYRENE ALYSE (BA)
Entity Type:Individual
Prefix:
First Name:SYRENE
Middle Name:ALYSE
Last Name:MILLER
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:SYRENE
Other - Middle Name:ALYSE
Other - Last Name:KOONS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:107 S DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1510
Mailing Address - Country:US
Mailing Address - Phone:509-838-4651
Mailing Address - Fax:509-363-2762
Practice Address - Street 1:2118 E SPRAGUE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-3125
Practice Address - Country:US
Practice Address - Phone:509-838-4651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61135315101Y00000X
390200000X
WASC611584111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program