Provider Demographics
NPI:1669545984
Name:MILLER, MARILYN D (PT)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:D
Last Name:MILLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9832 ZINNIA LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7701
Mailing Address - Country:US
Mailing Address - Phone:763-416-0505
Mailing Address - Fax:
Practice Address - Street 1:1300 GODWARD ST NE
Practice Address - Street 2:SUITE 1500
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-1741
Practice Address - Country:US
Practice Address - Phone:612-746-4747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN320225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN9B074MIOtherBCBS