Provider Demographics
NPI:1598299729
Name:MILLER, SARAH REBECCA
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:REBECCA
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 1:52437 LOST PONDEROSA RD
Mailing Address - Street 2:
Mailing Address - City:LA PINE
Mailing Address - State:OR
Mailing Address - Zip Code:97739-9519
Mailing Address - Country:US
Mailing Address - Phone:541-420-6653
Mailing Address - Fax:
Practice Address - Street 1:16493 BLUEWOOD PL # 5
Practice Address - Street 2:
Practice Address - City:LA PINE
Practice Address - State:OR
Practice Address - Zip Code:97739-7526
Practice Address - Country:US
Practice Address - Phone:541-536-5711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20107405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional