Healthcare Provider Details

I. General information

NPI: 1730647116
Provider Name (Legal Business Name): REBECCA JO MILLER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2019
Last Update Date: 03/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 S BRIDGEWAY PL
EAGLE ID
83616-6099
US

IV. Provider business mailing address

2608 S COLUMBUS ST
BOISE ID
83705-4340
US

V. Phone/Fax

Practice location:
  • Phone: 208-246-0123
  • Fax: 208-246-0125
Mailing address:
  • Phone: 208-866-4628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-7210
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: