Provider Demographics
NPI:1821540022
Name:MILLS, MIRIAM MINA (MFT INTERN)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:MINA
Last Name:MILLS
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:MIRIAM
Other - Middle Name:MICU
Other - Last Name:MINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1604 S SANTA FE AVE STE 403
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-5063
Mailing Address - Country:US
Mailing Address - Phone:951-654-2026
Mailing Address - Fax:951-654-9927
Practice Address - Street 1:1604 S SANTA FE AVE STE 403
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-5063
Practice Address - Country:US
Practice Address - Phone:951-654-2026
Practice Address - Fax:951-654-9927
Is Sole Proprietor?:No
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF77607106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist