Provider Demographics
NPI:1255752895
Name:MILLER, HOLLY
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
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 1:6077 STRATFORD RD NE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-9372
Mailing Address - Country:US
Mailing Address - Phone:541-570-5300
Mailing Address - Fax:
Practice Address - Street 1:537 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1919
Practice Address - Country:US
Practice Address - Phone:541-570-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-28
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60146148225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist