MEDICARE: DR. SHANNON MILLER PH.D.

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	103T00000X	Psychologist	018430	NY

General Provider Information

NPI Number	:	1871860239
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANNON MILLER PH.D.

Provider Business Mailing Address
First Line	:	709 MILAN HILL RD
Second Line	:
City	:	RED HOOK
State	:	NY
Zip	:	12571-4345
Country	:	US
Telephone Number	:	845-758-2874
Fax Number	:

Provider Business Practice Location Address
First Line	:	709 MILAN HILL RD
Second Line	:
City	:	RED HOOK
State	:	NY
Zip	:	12571-4345
Country	:	US
Telephone Number	:	845-758-2874
Fax Number	:

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

Provider Enumeration Date	:	11/29/2011
Last Update Date	:	11/29/2011

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