Provider Demographics
NPI:1760085229
Name:MILLER, SHELBY
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
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 1:10212 WILLOW LEAF DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-5681
Mailing Address - Country:US
Mailing Address - Phone:601-551-6089
Mailing Address - Fax:
Practice Address - Street 1:10212 WILLOW LEAF DR
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-5681
Practice Address - Country:US
Practice Address - Phone:601-551-6089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS14310750Medicaid