Provider Demographics
NPI:1629686167
Name:MILLER, SOPHIA (BCBA)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 W CARROLL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-1105
Mailing Address - Country:US
Mailing Address - Phone:312-733-0883
Mailing Address - Fax:
Practice Address - Street 1:1409 W CARROLL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-1105
Practice Address - Country:US
Practice Address - Phone:312-733-0883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
IN82502225800000X
IL1-23-66453103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist