Healthcare Provider Details

I. General information

NPI: 1114257615
Provider Name (Legal Business Name): MISS LAURA DALE MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2010
Last Update Date: 05/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 GAIL DR
EDMONTON KY
42129
US

IV. Provider business mailing address

111 GAIL DR
EDMONTON KY
42129-9300
US

V. Phone/Fax

Practice location:
  • Phone: 270-590-6958
  • Fax: 844-688-4227
Mailing address:
  • Phone: 270-590-6958
  • Fax: 844-688-4227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number201103230
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: