Provider Demographics
NPI:1528194834
Name:MILLER, CORTNEY
Entity Type:Individual
Prefix:
First Name:CORTNEY
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:PO BOX 1341
Mailing Address - Street 2:
Mailing Address - City:PERALTA
Mailing Address - State:NM
Mailing Address - Zip Code:87042-1341
Mailing Address - Country:US
Mailing Address - Phone:505-865-9577
Mailing Address - Fax:505-344-9343
Practice Address - Street 1:4216 BALLOON PARK RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5801
Practice Address - Country:US
Practice Address - Phone:505-865-9577
Practice Address - Fax:505-344-9343
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1774225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist