Provider Demographics
NPI:1063587608
Name:MILAM, NANCY R (PSYD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:R
Last Name:MILAM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 RONA PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-5739
Mailing Address - Country:US
Mailing Address - Phone:937-878-0612
Mailing Address - Fax:
Practice Address - Street 1:1250 W DOROTHY LN STE 208
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45409-1313
Practice Address - Country:US
Practice Address - Phone:937-298-9241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5617103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0701842Medicaid
OH0701842Medicaid
OHMICP28241Medicare ID - Type UnspecifiedPSYCHOLOGIST