Provider Demographics
NPI:1740436302
Name:MILLER, KARISSA DEANNE
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:DEANNE
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 1:2510 WOODHILL WAY
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2635
Mailing Address - Country:US
Mailing Address - Phone:208-410-7670
Mailing Address - Fax:
Practice Address - Street 1:1110 CALL CREEK DR STE 7
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3072
Practice Address - Country:US
Practice Address - Phone:208-410-7670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-14
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1670235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist