Provider Demographics
NPI:1285778852
Name:MILLER, LIESAL MARIE (MFT)
Entity type:Individual
Prefix:MRS
First Name:LIESAL
Middle Name:MARIE
Last Name:MILLER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S BALLARD AVE
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-3640
Mailing Address - Country:US
Mailing Address - Phone:469-757-4525
Mailing Address - Fax:
Practice Address - Street 1:205 S BALLARD AVE
Practice Address - Street 2:
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-3640
Practice Address - Country:US
Practice Address - Phone:469-757-4525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX202138106H00000X
CA49391106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA49391OtherCALIFORNIA BOARD OF BEHAVIORAL SCIENCES
TX202138OtherTEXAS STATE BOARD OF EXAMINERS OF MARRIAGE AND FAMILY THERAPISTS