Provider Demographics
NPI:1609440403
Name:MILLER, SHAKEEM MALIK
Entity type:Individual
Prefix:
First Name:SHAKEEM
Middle Name:MALIK
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 EMPEROR DR
Mailing Address - Street 2:
Mailing Address - City:SUISUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94585-2164
Mailing Address - Country:US
Mailing Address - Phone:707-366-8589
Mailing Address - Fax:
Practice Address - Street 1:814 EMPEROR DR
Practice Address - Street 2:
Practice Address - City:SUISUN CITY
Practice Address - State:CA
Practice Address - Zip Code:94585-2164
Practice Address - Country:US
Practice Address - Phone:707-366-8589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA93650023G68170Medicaid