Healthcare Provider Details

I. General information

NPI: 1750207536
Provider Name (Legal Business Name): LAURA GRADISHAR MILLER MSCP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 SOUTH PRAIRIE, UNIT G
SYCAMORE IN
60178
US

IV. Provider business mailing address

4720 LACEY AVE
LISLE IL
60532-1891
US

V. Phone/Fax

Practice location:
  • Phone: 779-269-4065
  • Fax:
Mailing address:
  • Phone: 818-782-2211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number1588395362
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: