Provider Demographics
NPI:1942501705
Name:MILLER, NICOLE MARIE-POUPENEY (HSPP)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MARIE-POUPENEY
Last Name:MILLER
Suffix:
Gender:F
Credentials:HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8495 CRATER LAKE HWY
Mailing Address - Street 2:BLDG. 240 RM 109 -MAIL STOP 116
Mailing Address - City:WHITE CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97503
Mailing Address - Country:US
Mailing Address - Phone:541-826-2111
Mailing Address - Fax:541-830-3516
Practice Address - Street 1:8495 CRATER LAKE HWY
Practice Address - Street 2:BLDG. 240 RM 109 -MAIL STOP 116
Practice Address - City:WHITE CITY
Practice Address - State:OR
Practice Address - Zip Code:97503
Practice Address - Country:US
Practice Address - Phone:541-826-2111
Practice Address - Fax:541-830-3516
Is Sole Proprietor?:No
Enumeration Date:2010-11-10
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042459A103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service