Provider Demographics
NPI:1871116400
Name:MILLER, ANNELISE NYSTROM
Entity type:Individual
Prefix:
First Name:ANNELISE
Middle Name:NYSTROM
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 1:3468 MT DIABLO BLVD STE B201
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-3959
Mailing Address - Country:US
Mailing Address - Phone:925-255-5350
Mailing Address - Fax:
Practice Address - Street 1:3468 MT DIABLO BLVD STE B201
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3959
Practice Address - Country:US
Practice Address - Phone:925-284-2298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-18
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty