Provider Demographics
NPI:1457859829
Name:MILLER, DENISE
Entity Type:Individual
Prefix:
First Name:DENISE
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 1:2035 FAIRMONT DR
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-1088
Mailing Address - Country:US
Mailing Address - Phone:510-346-7833
Mailing Address - Fax:
Practice Address - Street 1:2035 FAIRMONT DRIVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-9457
Practice Address - Country:US
Practice Address - Phone:510-346-7833
Practice Address - Fax:510-346-7832
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-31
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA011030315101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)