=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699911396
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY ABIGAIL STIFF MILLER PSY.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2008
-----------------------------------------------------
Last Update Date | 01/08/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1161 E BROADWAY
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40204-1711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-561-0952
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2024 SPEED AVE
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40205-1236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-767-8798
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 1524
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------