Provider Demographics
NPI:1619365608
Name:MILLER, CRYSTAL DAWN
Entity Type:Individual
Prefix:MISS
First Name:CRYSTAL
Middle Name:DAWN
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 1:1681 N MAITLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-3319
Mailing Address - Country:US
Mailing Address - Phone:800-840-2528
Mailing Address - Fax:407-540-9552
Practice Address - Street 1:1681 N MAITLAND AVE
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-3319
Practice Address - Country:US
Practice Address - Phone:800-840-2528
Practice Address - Fax:407-540-9552
Is Sole Proprietor?:No
Enumeration Date:2014-12-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 12747101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health