Healthcare Provider Details

I. General information

NPI: 1619365608
Provider Name (Legal Business Name): MISS CRYSTAL DAWN MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2014
Last Update Date: 12/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1681 N MAITLAND AVE
MAITLAND FL
32751-3319
US

IV. Provider business mailing address

1681 N MAITLAND AVE
MAITLAND FL
32751-3319
US

V. Phone/Fax

Practice location:
  • Phone: 800-840-2528
  • Fax: 407-540-9552
Mailing address:
  • Phone: 800-840-2528
  • Fax: 407-540-9552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH 12747
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: