Provider Demographics
NPI:1740615384
Name:MILLER, AUDREY JEAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:JEAN
Last Name:MILLER
Suffix:
Gender:F
Credentials:PSYD
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 745
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93448-0745
Mailing Address - Country:US
Mailing Address - Phone:805-471-3563
Mailing Address - Fax:
Practice Address - Street 1:1461 BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:GROVER BEACH
Practice Address - State:CA
Practice Address - Zip Code:93433-1890
Practice Address - Country:US
Practice Address - Phone:805-471-3563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-12
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30690103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist