Provider Demographics
NPI:1619253739
Name:MILLER, PHAEDRA NICOLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:PHAEDRA
Middle Name:NICOLE
Last Name:MILLER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 WESTERN DR APT L
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-3046
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:355 WESTERN DR APT L
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-3046
Practice Address - Country:US
Practice Address - Phone:813-966-1096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10644225XP0019X
HI990225XP0019X
FL8777225XP0019X
CO1789225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation