Provider Demographics
NPI:1861640294
Name:MILLER, MARK DOUGLAS (LMP)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:DOUGLAS
Last Name:MILLER
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10312 RAINIER AVE SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-4759
Mailing Address - Country:US
Mailing Address - Phone:253-820-3292
Mailing Address - Fax:
Practice Address - Street 1:10312 RAINIER AVE SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-4759
Practice Address - Country:US
Practice Address - Phone:253-820-3292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-27
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022515172V00000X
WA00022515225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No172V00000XOther Service ProvidersCommunity Health Worker