Provider Demographics
NPI:1760551774
Name:MILLER, MARY SUSANNE (MA, LLP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:SUSANNE
Last Name:MILLER
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8191 41.5 RD
Mailing Address - Street 2:
Mailing Address - City:RAPID RIVER
Mailing Address - State:MI
Mailing Address - Zip Code:49878-9719
Mailing Address - Country:US
Mailing Address - Phone:906-446-3658
Mailing Address - Fax:
Practice Address - Street 1:N15019 HANNAHVILLE B1 RD.
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:MI
Practice Address - Zip Code:49896
Practice Address - Country:US
Practice Address - Phone:906-466-2878
Practice Address - Fax:906-466-9144
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008913103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist