Provider Demographics
NPI:1497052062
Name:MILLER, TANYA (COTA/L)
Entity Type:Individual
Prefix:MISS
First Name:TANYA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CIVIC PLAZA DR STE 625
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-7986
Mailing Address - Country:US
Mailing Address - Phone:310-549-4500
Mailing Address - Fax:310-549-4700
Practice Address - Street 1:1 CIVIC PLAZA DR STE 625
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-7986
Practice Address - Country:US
Practice Address - Phone:310-549-4500
Practice Address - Fax:310-549-4700
Is Sole Proprietor?:No
Enumeration Date:2011-02-17
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA969732171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA16-1216796Medicare PIN