Provider Demographics
NPI:1619178977
Name:MILLER, RANDOLPH EVERETT (MFT)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:EVERETT
Last Name:MILLER
Suffix:
Gender:M
Credentials:MFT
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 100 PMB 220
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546-0100
Mailing Address - Country:US
Mailing Address - Phone:760-812-9599
Mailing Address - Fax:
Practice Address - Street 1:452 OLD MAMMOTH ROAD
Practice Address - Street 2:
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546
Practice Address - Country:US
Practice Address - Phone:760-812-9599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106HO0000XMedicare UPIN