Provider Demographics
NPI:1487024097
Name:MILLER, MELISSA (PSYD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:KURKOSKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10333 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422
Mailing Address - Country:US
Mailing Address - Phone:805-468-2000
Mailing Address - Fax:
Practice Address - Street 1:10333 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422
Practice Address - Country:US
Practice Address - Phone:805-468-2750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-25
Last Update Date:2021-02-05
Deactivation Date:2020-10-07
Deactivation Code:
Reactivation Date:2020-10-14
Provider Licenses
StateLicense IDTaxonomies
CA32119103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical