Healthcare Provider Details

I. General information

NPI: 1912162587
Provider Name (Legal Business Name): GINI M. MILLER MS CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2008
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 PLUM COURT DR
POUGHQUAG NY
12570-4504
US

IV. Provider business mailing address

45 PLUM COURT DR
POUGHQUAG NY
12570-4504
US

V. Phone/Fax

Practice location:
  • Phone: 845-724-5636
  • Fax:
Mailing address:
  • Phone: 845-724-5636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number015152
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: