Provider Demographics
NPI:1205506540
Name:MILEY, LYSA R
Entity type:Individual
Prefix:MS
First Name:LYSA
Middle Name:R
Last Name:MILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3720 W WOODMONT DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-1033
Mailing Address - Country:US
Mailing Address - Phone:209-703-0050
Mailing Address - Fax:
Practice Address - Street 1:992 W IDAHO AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2111
Practice Address - Country:US
Practice Address - Phone:208-741-3336
Practice Address - Fax:541-216-5066
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker