Provider Demographics
NPI:1386124642
Name:MILLER, GLORIA DAVEDA
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:DAVEDA
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709A WOODLAND PL
Mailing Address - Street 2:
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75110-1010
Mailing Address - Country:US
Mailing Address - Phone:815-575-5281
Mailing Address - Fax:
Practice Address - Street 1:809 NE 4TH ST
Practice Address - Street 2:
Practice Address - City:KERENS
Practice Address - State:TX
Practice Address - Zip Code:75144-2715
Practice Address - Country:US
Practice Address - Phone:903-396-3211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1204466225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist