Healthcare Provider Details

I. General information

NPI: 1740510528
Provider Name (Legal Business Name): STACY MILLER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2009
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 VASSAR DR NE BLDG 23
ALBUQUERQUE NM
87106-2725
US

IV. Provider business mailing address

801 VASSAR DR NE BLDG 23
ALBUQUERQUE NM
87106-2725
US

V. Phone/Fax

Practice location:
  • Phone: 505-248-4087
  • Fax: 505-256-6844
Mailing address:
  • Phone: 505-248-4087
  • Fax: 505-256-6844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4304
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4304
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: