Provider Demographics
NPI:1134175300
Name:MILLER, MARY ANNA (LP)
Entity type:Individual
Prefix:
First Name:MARY ANNA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19839 EMPEROR CT
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-8431
Mailing Address - Country:US
Mailing Address - Phone:651-463-8026
Mailing Address - Fax:
Practice Address - Street 1:6950 146TH ST W
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-4513
Practice Address - Country:US
Practice Address - Phone:952-432-1484
Practice Address - Fax:952-432-2328
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4145103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN546M7MIOtherBCBS
MNHP29388OtherHEALTHPARTNERS
MNP00331391OtherRR MEDICARE
MN6154468OtherMEDICA CHOICE