Provider Demographics
NPI:1629778535
Name:MILLER, DEJA LORRAINE
Entity Type:Individual
Prefix:
First Name:DEJA
Middle Name:LORRAINE
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 1:7596 TWILIGHT DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95822-5740
Mailing Address - Country:US
Mailing Address - Phone:916-544-4986
Mailing Address - Fax:
Practice Address - Street 1:3120 FREEBOARD DR STE 102
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691-5039
Practice Address - Country:US
Practice Address - Phone:530-351-7975
Practice Address - Fax:530-351-7976
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program