Provider Demographics
NPI:1790242196
Name:MILLER, RENAE (MS, OTR/L, CIMI)
Entity Type:Individual
Prefix:
First Name:RENAE
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:MS, OTR/L, CIMI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 BREAKWATER CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-7702
Mailing Address - Country:US
Mailing Address - Phone:910-922-1285
Mailing Address - Fax:
Practice Address - Street 1:4142 BONNEY RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1711
Practice Address - Country:US
Practice Address - Phone:757-340-0620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11609225XG0600X, 225XP0019X
VA0119-007629225XP0019X, 225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation