Provider Demographics
NPI:1629499611
Name:MILLER, BETSY OLIVIA
Entity Type:Individual
Prefix:
First Name:BETSY
Middle Name:OLIVIA
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:PO BOX 195
Mailing Address - Street 2:
Mailing Address - City:PAWNEE
Mailing Address - State:IL
Mailing Address - Zip Code:62558-0195
Mailing Address - Country:US
Mailing Address - Phone:217-254-5542
Mailing Address - Fax:
Practice Address - Street 1:2035 W ILES AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4192
Practice Address - Country:US
Practice Address - Phone:217-679-5080
Practice Address - Fax:217-679-5386
Is Sole Proprietor?:No
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILM460-0749-0640222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILM460-0749-0640OtherDRIVERS LICENSE