Provider Demographics
NPI:1205513751
Name:MILLER, BOBBI SUE (MT)
Entity type:Individual
Prefix:
First Name:BOBBI
Middle Name:SUE
Last Name:MILLER
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12723 ROUTE 19 S STE 100
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16441-9027
Mailing Address - Country:US
Mailing Address - Phone:814-796-0077
Mailing Address - Fax:814-796-1717
Practice Address - Street 1:12723 ROUTE 19 S STE 100
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:PA
Practice Address - Zip Code:16441-9027
Practice Address - Country:US
Practice Address - Phone:814-796-0077
Practice Address - Fax:814-796-1717
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG009421225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist