Provider Demographics
NPI:1144254277
Name:MILLER, MONIQUE MASSA (MS LP)
Entity type:Individual
Prefix:MR
First Name:MONIQUE
Middle Name:MASSA
Last Name:MILLER
Suffix:
Gender:F
Credentials:MS LP
Other - Prefix:MS
Other - First Name:MONIQUE
Other - Middle Name:MARIE
Other - Last Name:MASSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:1321 13TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2614
Mailing Address - Country:US
Mailing Address - Phone:320-252-5010
Mailing Address - Fax:320-203-1855
Practice Address - Street 1:308 12TH AVE S
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-2321
Practice Address - Country:US
Practice Address - Phone:763-682-4400
Practice Address - Fax:763-682-1353
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3375103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
922241042329OtherPREFERRED ONE
922S7MIOtherBCBS
6178046OtherMEDICA
HP48657OtherHEALTH PARTNERS