Healthcare Provider Details

I. General information

NPI: 1093383937
Provider Name (Legal Business Name): ELIZABETH MILLER RN, QMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH PFAFF

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 09/30/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 OLIVER ST
VIENNA IL
62995-1660
US

IV. Provider business mailing address

101 OLIVER ST
VIENNA IL
62995-1660
US

V. Phone/Fax

Practice location:
  • Phone: 618-658-2611
  • Fax: 618-658-2501
Mailing address:
  • Phone: 618-658-2611
  • Fax: 618-658-2501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041406472
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: