Provider Demographics
NPI:1932168564
Name:MILLER, THERESA ANN (PHD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:MILLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:ANN
Other - Last Name:MILLER-ETOLL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 94508
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87199-4508
Mailing Address - Country:US
Mailing Address - Phone:505-384-7353
Mailing Address - Fax:505-384-7354
Practice Address - Street 1:5600 WYOMING BLVD NE
Practice Address - Street 2:SUITE 240
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109
Practice Address - Country:US
Practice Address - Phone:505-384-7353
Practice Address - Fax:505-384-7354
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0786103TC1900X
NMNM786103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMAAA0350Medicare PIN