Provider Demographics
NPI:1780009761
Name:MILLER, SHELLY
Entity Type:Individual
Prefix:
First Name:SHELLY
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 1:5875 STATE ROUTE 193
Mailing Address - Street 2:
Mailing Address - City:KINGSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44048-9794
Mailing Address - Country:US
Mailing Address - Phone:440-224-0281
Mailing Address - Fax:
Practice Address - Street 1:5875 STATE ROUTE 193
Practice Address - Street 2:
Practice Address - City:KINGSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44048-9794
Practice Address - Country:US
Practice Address - Phone:440-224-0281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-27
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS 00126981041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool