Provider Demographics
NPI:1700521564
Name:MILLER, RADIANT KHALIL (PTCB, PCA)
Entity type:Individual
Prefix:
First Name:RADIANT
Middle Name:KHALIL
Last Name:MILLER
Suffix:
Gender:F
Credentials:PTCB, PCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5801 RIVERDALE RD APT 48L
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-6878
Mailing Address - Country:US
Mailing Address - Phone:678-973-5791
Mailing Address - Fax:
Practice Address - Street 1:5801 RIVERDALE RD APT 48L
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-6878
Practice Address - Country:US
Practice Address - Phone:678-973-5791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-04
Last Update Date:2022-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable