Healthcare Provider Details

I. General information

NPI: 1376300079
Provider Name (Legal Business Name): GRACELYNN GENE MILLER PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/29/2024
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 W STEWART DR STE 404
ORANGE CA
92868-3855
US

IV. Provider business mailing address

2003 W ATKINSON RD
OTHELLO WA
99344-9744
US

V. Phone/Fax

Practice location:
  • Phone: 714-707-6466
  • Fax:
Mailing address:
  • Phone: 509-954-9499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT61526686
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number305768
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: