Provider Demographics
NPI:1821762998
Name:MILLER, KALLIE LAUREL (OTR/L)
Entity Type:Individual
Prefix:
First Name:KALLIE
Middle Name:LAUREL
Last Name:MILLER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 MIRA MAR AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-6724
Mailing Address - Country:US
Mailing Address - Phone:504-813-0956
Mailing Address - Fax:
Practice Address - Street 1:620 N LAKE AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1220
Practice Address - Country:US
Practice Address - Phone:626-793-7350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22450225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist