Provider Demographics
NPI:1639798192
Name:MILLER, SHANTE MONIQUE (CO 61037377)
Entity Type:Individual
Prefix:
First Name:SHANTE
Middle Name:MONIQUE
Last Name:MILLER
Suffix:
Gender:F
Credentials:CO 61037377
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E FREMONT ST APT B103
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-2364
Mailing Address - Country:US
Mailing Address - Phone:504-417-6938
Mailing Address - Fax:206-223-1482
Practice Address - Street 1:2601 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3309
Practice Address - Country:US
Practice Address - Phone:425-258-2407
Practice Address - Fax:425-339-2601
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61037377390200000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)