Provider Demographics
NPI:1912581521
Name:MILLER, TINA
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
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 1:172 COTTAGE DR
Mailing Address - Street 2:
Mailing Address - City:HORTON
Mailing Address - State:MI
Mailing Address - Zip Code:49246-9727
Mailing Address - Country:US
Mailing Address - Phone:586-321-6179
Mailing Address - Fax:
Practice Address - Street 1:31700 W 12 MILE RD STE 100&250
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-4424
Practice Address - Country:US
Practice Address - Phone:586-321-6179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009261103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist