Provider Demographics
NPI:1265761613
Name:MILIUS, MONIQUE G (LMT)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:G
Last Name:MILIUS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3186 MELBOURNE ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-3951
Mailing Address - Country:US
Mailing Address - Phone:801-647-8158
Mailing Address - Fax:
Practice Address - Street 1:3186 MELBOURNE ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-3951
Practice Address - Country:US
Practice Address - Phone:801-647-8158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT354657-4701174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist