Healthcare Provider Details

I. General information

NPI: 1639798192
Provider Name (Legal Business Name): SHANTE MONIQUE MILLER CO 61037377
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2020
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 SUMMIT AVE
EVERETT WA
98201-3309
US

IV. Provider business mailing address

500 E FREMONT ST APT B103
MONROE WA
98272-2364
US

V. Phone/Fax

Practice location:
  • Phone: 425-258-2407
  • Fax: 425-339-2601
Mailing address:
  • Phone: 504-417-6938
  • Fax: 206-223-1482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO61037377
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberCO61037377
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: