Healthcare Provider Details

I. General information

NPI: 1396998605
Provider Name (Legal Business Name): MICHAEL S. MILLER LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2008
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 MISSISSIPPI ST S
WYNNE AR
72396-3025
US

IV. Provider business mailing address

6462 CROSSBROOK LN APT 5
MEMPHIS TN
38134-7896
US

V. Phone/Fax

Practice location:
  • Phone: 870-208-8499
  • Fax:
Mailing address:
  • Phone: 501-519-2482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP1412114
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: