Provider Demographics
NPI:1639567217
Name:MILLER, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPCC
Mailing Address - Street 1:350 INTERLOCKEN BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80021-3478
Mailing Address - Country:US
Mailing Address - Phone:720-523-1116
Mailing Address - Fax:720-523-1116
Practice Address - Street 1:350 INTERLOCKEN BLVD
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80021-3477
Practice Address - Country:US
Practice Address - Phone:720-523-1116
Practice Address - Fax:720-523-1116
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
COLPCC.0015805101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
COLPCC.0015805OtherNO MEDICAID