Provider Demographics
NPI:1376761585
Name:MILLER-EDGE, ANN D (LADC/MH)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:D
Last Name:MILLER-EDGE
Suffix:
Gender:F
Credentials:LADC/MH
Other - Prefix:
Other - First Name:ANNI
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3705 N MERIDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2817
Mailing Address - Country:US
Mailing Address - Phone:405-367-1426
Mailing Address - Fax:
Practice Address - Street 1:3705 N MERIDIAN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2817
Practice Address - Country:US
Practice Address - Phone:405-367-1426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1030101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200079250 AMedicaid