Healthcare Provider Details

I. General information

NPI: 1104009901
Provider Name (Legal Business Name): MS. LEEANNA MARIE MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. LEEANNA MARIE CASTOR

II. Dates (important events)

Enumeration Date: 12/14/2007
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12125 SHALE RIDGE LN
AUBURN CA
95602-8880
US

IV. Provider business mailing address

12125 SHALE RIDGE LN
AUBURN CA
95602-8880
US

V. Phone/Fax

Practice location:
  • Phone: 530-885-1917
  • Fax:
Mailing address:
  • Phone: 530-885-1917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1397900720
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: