Basic Information
| Provider Information | |||||||||
| NPI: | 1124401195 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | M.S. CF-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8128 AM LUTTRELL ROAD | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5404212604 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4502 W 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802042917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7202721289 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2015 | ||||||||
| LastUpdateDate: | 03/05/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/23/2019 | ||||||||
| NPIReactivationDate: | 03/05/2019 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 6678 | TN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.