Healthcare Provider Details

I. General information

NPI: 1003685579
Provider Name (Legal Business Name): DOMINIC MARCO MILLER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2023
Last Update Date: 12/26/2023
Certification Date: 12/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 N 3RD ST
PHOENIX AZ
85012-2331
US

IV. Provider business mailing address

PO BOX 1671
PHOENIX AZ
85001-1671
US

V. Phone/Fax

Practice location:
  • Phone: 602-265-8338
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-21218
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: