Provider Demographics
NPI:1912214230
Name:MILLER, STEPHANIE NICOLE (PHD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:MILLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3211 W DE LEON ST
Mailing Address - Street 2:#17
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4689
Mailing Address - Country:US
Mailing Address - Phone:765-617-5806
Mailing Address - Fax:
Practice Address - Street 1:3211 W DE LEON ST
Practice Address - Street 2:#17
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4689
Practice Address - Country:US
Practice Address - Phone:765-617-5806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010006121103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical