Provider Demographics
NPI:1528160041
Name:MILLER, TIMOTHY R (PHD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:MILLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5250 CLAREMONT AVE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5700
Mailing Address - Country:US
Mailing Address - Phone:209-478-8568
Mailing Address - Fax:209-472-3439
Practice Address - Street 1:5250 CLAREMONT AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5700
Practice Address - Country:US
Practice Address - Phone:209-478-8568
Practice Address - Fax:209-472-3439
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8283103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY8283OtherPSYCHOLOGY LICENSE NUMBER