Provider Demographics
NPI:1265413777
Name:MILLER, STANLEY R (PSYD,LP)
Entity type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:R
Last Name:MILLER
Suffix:
Gender:M
Credentials:PSYD,LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 15TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-1911
Mailing Address - Country:US
Mailing Address - Phone:507-433-6482
Mailing Address - Fax:507-433-0097
Practice Address - Street 1:1403 15TH AVE NW
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-1911
Practice Address - Country:US
Practice Address - Phone:507-433-6482
Practice Address - Fax:507-433-0097
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3235103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist