Basic Information
Provider Information | |||||||||
NPI: | 1801972617 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILLER | ||||||||
FirstName: | CARRIE | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S.,CCC-A | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 8310 | ||||||||
Address2: |   | ||||||||
City: | ROANOKE | ||||||||
State: | VA | ||||||||
PostalCode: | 240140310 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5403453556 | ||||||||
FaxNumber: | 5403422193 | ||||||||
Practice Location | |||||||||
Address1: | 2030 COLONIAL AVE SW | ||||||||
Address2: |   | ||||||||
City: | ROANOKE | ||||||||
State: | VA | ||||||||
PostalCode: | 240153204 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5403430165 | ||||||||
FaxNumber: | 5403454664 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/27/2006 | ||||||||
LastUpdateDate: | 08/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 2201001156 | VA | Y |   | Speech, Language and Hearing Service Providers | Audiologist |   | 237600000X | 2101001383 | VA | N |   | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |   |
ID Information
ID | Type | State | Issuer | Description | 009105727 | 05 | VA |   | MEDICAID | 240052 | 01 | VA | MAMSI | OTHER | 010197554 | 05 | VA |   | MEDICAID | 0007926527 | 01 | VA | AETNA | OTHER | 297809 | 01 | VA | MAMSI | OTHER | 384444 | 01 | VA | ANTHEM | OTHER |