Provider Demographics
NPI:1457525750
Name:MILLER, THERESA (INDEPENDENT PROVIDER)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:INDEPENDENT PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 680729
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32868
Mailing Address - Country:US
Mailing Address - Phone:407-522-7970
Mailing Address - Fax:407-522-7970
Practice Address - Street 1:2942 HICKORY CREEK DRIVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818
Practice Address - Country:US
Practice Address - Phone:407-522-7970
Practice Address - Fax:407-522-7970
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL385HR2065X385HR2065X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL692253898Medicaid
FL692253896Medicaid