Healthcare Provider Details

I. General information

NPI: 1932168564
Provider Name (Legal Business Name): THERESA ANN MILLER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: THERESA ANN MILLER-ETOLL PHD

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 07/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5600 WYOMING BLVD NE SUITE 240
ALBUQUERQUE NM
87109
US

IV. Provider business mailing address

PO BOX 94508
ALBUQUERQUE NM
87199-4508
US

V. Phone/Fax

Practice location:
  • Phone: 505-384-7353
  • Fax: 505-384-7354
Mailing address:
  • Phone: 505-384-7353
  • Fax: 505-384-7354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number0786
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberNM786
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: