Provider Demographics
NPI:1609238096
Name:MILLER, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 BRES AVE STE G
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5869
Mailing Address - Country:US
Mailing Address - Phone:318-509-8073
Mailing Address - Fax:
Practice Address - Street 1:215 BRES AVE STE G
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5869
Practice Address - Country:US
Practice Address - Phone:318-509-8073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8864631322D00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children