Provider Demographics
NPI:1285136259
Name:MILLER, BROCK EDWIN (SLP)
Entity type:Individual
Prefix:
First Name:BROCK
Middle Name:EDWIN
Last Name:MILLER
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1047 COUNTY ROAD 254
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-7574
Mailing Address - Country:US
Mailing Address - Phone:254-979-2341
Mailing Address - Fax:
Practice Address - Street 1:15820 ADDISON RD
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-3549
Practice Address - Country:US
Practice Address - Phone:866-919-3240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112050235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist