Healthcare Provider Details

I. General information

NPI: 1619178977
Provider Name (Legal Business Name): RANDOLPH EVERETT MILLER MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

452 OLD MAMMOTH ROAD
MAMMOTH LAKES CA
93546
US

IV. Provider business mailing address

PO BOX 100 PMB 220
MAMMOTH LAKES CA
93546-0100
US

V. Phone/Fax

Practice location:
  • Phone: 760-812-9599
  • Fax:
Mailing address:
  • Phone: 760-812-9599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: