Provider Demographics
NPI:1730753609
Name:MILLER, IVY DESDEMONA
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:DESDEMONA
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 E HERBERT AVE APT B
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-4743
Mailing Address - Country:US
Mailing Address - Phone:775-340-9555
Mailing Address - Fax:
Practice Address - Street 1:370 E HERBERT AVE APT B
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-4743
Practice Address - Country:US
Practice Address - Phone:775-340-9555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-16
Last Update Date:2021-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician