Healthcare Provider Details

I. General information

NPI: 1063904654
Provider Name (Legal Business Name): TANISHA MILLER LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 01/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 BOARDMAN CANFIELD RD STE L1
YOUNGSTOWN OH
44512-4370
US

IV. Provider business mailing address

725 BOARDMAN CANFIELD RD STE L1
YOUNGSTOWN OH
44512-4370
US

V. Phone/Fax

Practice location:
  • Phone: 330-797-0074
  • Fax:
Mailing address:
  • Phone: 330-330-8655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.1800990
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: