Provider Demographics
NPI:1972702298
Name:MARTHA GAIL MILLER
Entity Type:Organization
Organization Name:MARTHA GAIL MILLER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR/PROGRAM MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:GAIL
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-288-3583
Mailing Address - Street 1:16103 SAINT PAUL DR
Mailing Address - Street 2:
Mailing Address - City:MALAKOFF
Mailing Address - State:TX
Mailing Address - Zip Code:75148-4370
Mailing Address - Country:US
Mailing Address - Phone:903-288-3583
Mailing Address - Fax:903-489-1814
Practice Address - Street 1:16103 SAINT PAUL DR
Practice Address - Street 2:
Practice Address - City:MALAKOFF
Practice Address - State:TX
Practice Address - Zip Code:75148-4370
Practice Address - Country:US
Practice Address - Phone:903-288-3583
Practice Address - Fax:903-489-1814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX320900000320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities