Provider Demographics
NPI:1558873414
Name:MILLER, AMY M (BA, SSP, NCSP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:MILLER
Suffix:
Gender:F
Credentials:BA, SSP, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-1652
Mailing Address - Country:US
Mailing Address - Phone:618-833-4541
Mailing Address - Fax:618-833-4833
Practice Address - Street 1:1000 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-1652
Practice Address - Country:US
Practice Address - Phone:618-833-4541
Practice Address - Fax:618-833-4833
Is Sole Proprietor?:No
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1830850103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool