Basic Information
Provider Information | |||||||||
NPI: | 1922467893 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILLER | ||||||||
FirstName: | MESA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CCC-SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 602 VONDERBURG DR | ||||||||
Address2: | SUITE 201 | ||||||||
City: | BRANDON | ||||||||
State: | FL | ||||||||
PostalCode: | 335115900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8136531149 | ||||||||
FaxNumber: | 8136546644 | ||||||||
Practice Location | |||||||||
Address1: | 2401 NW 23RD ST STE 2D | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731072420 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4053553239 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/19/2016 | ||||||||
LastUpdateDate: | 07/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SLP009162 | GA | N |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 235Z00000X | SA15263 | FL | N |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 235Z00000X | 5621 | OK | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
ID Information
ID | Type | State | Issuer | Description | 020571900 | 05 | FL |   | MEDICAID |