Provider Demographics
NPI:1538873955
Name:MILLER, ELLIE L (PSYD)
Entity type:Individual
Prefix:DR
First Name:ELLIE
Middle Name:L
Last Name:MILLER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:MS
Other - First Name:ELLIE
Other - Middle Name:L
Other - Last Name:OTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:405 WORTHING CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-4659
Mailing Address - Country:US
Mailing Address - Phone:502-396-7804
Mailing Address - Fax:
Practice Address - Street 1:4205 SPRINGHURST BLVD STE 202
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-6160
Practice Address - Country:US
Practice Address - Phone:502-618-2060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY278384103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service