Healthcare Provider Details

I. General information

NPI: 1902440142
Provider Name (Legal Business Name): ROSE DIANE MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2019
Last Update Date: 10/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 NW 6TH ST
GAINESVILLE FL
32601-4245
US

IV. Provider business mailing address

1208 NW 6TH ST
GAINESVILLE FL
32601-4245
US

V. Phone/Fax

Practice location:
  • Phone: 352-379-2829
  • Fax: 352-379-2843
Mailing address:
  • Phone: 352-379-2829
  • Fax: 352-379-2843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH-2429
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: