Provider Demographics
NPI:1417437997
Name:MILLER, MALLORIE
Entity Type:Individual
Prefix:
First Name:MALLORIE
Middle Name:
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 1:479 JOACHIM AVE
Mailing Address - Street 2:
Mailing Address - City:HERCULANEUM
Mailing Address - State:MO
Mailing Address - Zip Code:63048-1034
Mailing Address - Country:US
Mailing Address - Phone:636-479-5200
Mailing Address - Fax:
Practice Address - Street 1:479 JOACHIM AVE
Practice Address - Street 2:
Practice Address - City:HERCULANEUM
Practice Address - State:MO
Practice Address - Zip Code:63048-1034
Practice Address - Country:US
Practice Address - Phone:636-479-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017031300235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist