Basic Information
Provider Information | |||||||||
NPI: | 1275628281 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILLER | ||||||||
FirstName: | AYISHA | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KELLYBREW | ||||||||
OtherFirstName: | AYISHA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PHD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1312 DONAGHEY AVE | ||||||||
Address2: | SUITE 1 | ||||||||
City: | CONWAY | ||||||||
State: | AR | ||||||||
PostalCode: | 720343807 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5013368300 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1312 DONAGHEY AVE | ||||||||
Address2: |   | ||||||||
City: | CONWAY | ||||||||
State: | AR | ||||||||
PostalCode: | 720343807 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5013663600 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2006 | ||||||||
LastUpdateDate: | 03/18/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | P0409039 | AR | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X |   | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.