Provider Demographics
NPI:1730647116
Name:MILLER, REBECCA JO (LPC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:JO
Last Name:MILLER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2608 S COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-4340
Mailing Address - Country:US
Mailing Address - Phone:208-866-4628
Mailing Address - Fax:
Practice Address - Street 1:1032 S BRIDGEWAY PL
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6099
Practice Address - Country:US
Practice Address - Phone:208-246-0123
Practice Address - Fax:208-246-0125
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-7210101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLPC-7210Medicaid