Provider Demographics
NPI:1205542990
Name:MILLER, MAKENZIE HOPE
Entity type:Individual
Prefix:
First Name:MAKENZIE
Middle Name:HOPE
Last Name:MILLER
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 1:180 GLENSHEE CT
Mailing Address - Street 2:
Mailing Address - City:SHALLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28470-3300
Mailing Address - Country:US
Mailing Address - Phone:843-360-8533
Mailing Address - Fax:
Practice Address - Street 1:10926 S TRYON ST STE E
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-4154
Practice Address - Country:US
Practice Address - Phone:855-201-5498
Practice Address - Fax:888-849-4249
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician