Individual provider Active NPI

D'Lane Sally Miller, PH.D.

  • Clinical Psychologist
  • Fort Walton Beach, FL
National Provider Identifier
1124098504
Registry record updated Dec 8, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical PsychologistTaxonomy code 103TC0700X
License
PY00003359 Issued in FL
Practice address
404 Barataria LN
Fort Walton Beach, FL 32547-3698
Phone
(850) 243-8086
Fax
(850) 243-2702
NPI assigned
Jan 26, 2006
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Dec 8, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Psychologist 103TC0700X PY00003359 FL Primary

Addresses

Primary practice location

404 Barataria LN
Fort Walton Beach, FL 32547-3698

Mailing address

404 Barataria LN
Fort Walton Beach, FL 32547-3698
Phone (850) 243-8086

Other practice location 1

124 E Miracle Strip Pkwy
Suite 302
Mary Esther, FL 32569-1988
Phone (850) 243-8086

Other identifiers 3

IdentifierTypeStateIssuer
59-3736816OtherFLGROUP TAX ID
75407OtherFLBCBS
7944548OtherAETNA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL
Eligible to order & refer
  • Part B services: Yes
  • Medical equipment: Yes
  • Home health: No
  • Power mobility devices: No
  • Hospice: No
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20110511000036 FL Practitioner - Clinical Psychologist 7315123247 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Clinical Psychologist
Education
Other, 1981
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices

Practice addresses (Care Compare)

404 Barataria LN
Fort Walton Beach, FL 32547-3698
Phone (850) 243-8086

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Philosophy

State licenses

LicenseStateTypeSpecialty
PY00003359FLMDClinical Psychologist

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1138233600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1733616000000",
    "number": "1124098504",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "404 BARATARIA LN",
            "city": "FORT WALTON BEACH",
            "state": "FL",
            "postal_code": "325473698",
            "telephone_number": "850-243-8086",
            "fax_number": "850-243-2702"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "404 BARATARIA LN",
            "city": "FORT WALTON BEACH",
            "state": "FL",
            "postal_code": "325473698",
            "telephone_number": "850-243-8086",
            "fax_number": "850-243-2702"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "124 E Miracle Strip Pkwy",
            "address_2": "Suite 302",
            "address_purpose": "LOCATION",
            "city": "Mary Esther",
            "state": "FL",
            "postal_code": "325691988",
            "country_code": "US",
            "telephone_number": "850-243-8086",
            "fax_number": "850-243-2702",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "MILLER",
        "first_name": "D'LANE",
        "middle_name": "SALLY",
        "name_prefix": "Dr.",
        "credential": "PH.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-01-26",
        "last_updated": "2024-12-08",
        "certification_date": "2024-12-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "FL",
            "license": "PY00003359",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP TAX ID",
            "identifier": "59-3736816",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "75407",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA",
            "identifier": "7944548",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Walton Beach, FL

Sources for this page

Verify at the official NPI Registry.