Provider Demographics
NPI:1720470354
Name:MILLER, REBECCA (LPC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 JAY ST
Mailing Address - Street 2:
Mailing Address - City:BLUE RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:53518-9435
Mailing Address - Country:US
Mailing Address - Phone:608-391-2436
Mailing Address - Fax:
Practice Address - Street 1:406 ELM ST
Practice Address - Street 2:
Practice Address - City:BOSCOBEL
Practice Address - State:WI
Practice Address - Zip Code:53805-1216
Practice Address - Country:US
Practice Address - Phone:608-391-2436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-18
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6454125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1720470354Medicaid