Provider Demographics
NPI:1124341250
Name:MILLER, MICHELLE L (ATC)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:L
Last Name:MILLER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 E OAK ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FAIRBURY
Mailing Address - State:IL
Mailing Address - Zip Code:61739-1390
Mailing Address - Country:US
Mailing Address - Phone:815-692-6200
Mailing Address - Fax:815-692-6202
Practice Address - Street 1:902 E OAK ST
Practice Address - Street 2:SUITE 3
Practice Address - City:FAIRBURY
Practice Address - State:IL
Practice Address - Zip Code:61739-1390
Practice Address - Country:US
Practice Address - Phone:815-692-6200
Practice Address - Fax:815-692-6202
Is Sole Proprietor?:No
Enumeration Date:2010-03-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL96.0007582255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer