Provider Demographics
NPI:1639750250
Name:MILLER, MICHELLE RENEE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
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 1:208 SE YORKTOWN DR
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5850
Mailing Address - Country:US
Mailing Address - Phone:971-777-9759
Mailing Address - Fax:
Practice Address - Street 1:1607 WILLIAMS HWY STE 6
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5674
Practice Address - Country:US
Practice Address - Phone:971-777-9759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25990225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist