Provider Demographics
NPI:1841609047
Name:MILLER, CORY (BCABA)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2112
Mailing Address - Street 2:A8
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33806-2112
Mailing Address - Country:US
Mailing Address - Phone:863-619-2809
Mailing Address - Fax:863-644-9590
Practice Address - Street 1:145 E EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4014
Practice Address - Country:US
Practice Address - Phone:863-619-2809
Practice Address - Fax:863-644-9590
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-13
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1841609047106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst