MEDICARE: MIRIAM MINA MILLS MFT INTERN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	IMF77607	CA

General Provider Information

NPI Number	:	1821540022
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRIAM MINA MILLS MFT INTERN

Provider Business Mailing Address
First Line	:	1604 S SANTA FE AVE STE 403
Second Line	:
City	:	SAN JACINTO
State	:	CA
Zip	:	92583-5063
Country	:	US
Telephone Number	:	951-654-2026
Fax Number	:	951-654-9927

Provider Business Practice Location Address
First Line	:	1604 S SANTA FE AVE STE 403
Second Line	:
City	:	SAN JACINTO
State	:	CA
Zip	:	92583-5063
Country	:	US
Telephone Number	:	951-654-2026
Fax Number	:	951-654-9927

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2016
Last Update Date	:	11/04/2016

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