Healthcare Provider Details

I. General information

NPI: 1245580521
Provider Name (Legal Business Name): TAMMY M MILLER PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2012
Last Update Date: 01/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 PRIEST BRIDGE DR STE 1
CROFTON MD
21114-2472
US

IV. Provider business mailing address

2110 PRIEST BRIDGE DR STE 1
CROFTON MD
21114-2472
US

V. Phone/Fax

Practice location:
  • Phone: 443-937-7089
  • Fax: 443-292-4570
Mailing address:
  • Phone: 443-937-7089
  • Fax: 800-353-1668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number05998
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2012-64
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: