Provider Demographics
NPI:1912128018
Name:MILLER, LISA JEANETTE (MED)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JEANETTE
Last Name:MILLER
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61279 FAIRFIELD DRIVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-2735
Mailing Address - Country:US
Mailing Address - Phone:541-317-5803
Mailing Address - Fax:
Practice Address - Street 1:1379 SW 15TH ST
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-2905
Practice Address - Country:US
Practice Address - Phone:541-548-6166
Practice Address - Fax:541-548-6168
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT68066101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional