Healthcare Provider Details

I. General information

NPI: 1205452679
Provider Name (Legal Business Name): DUSTIN MILLER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2020
Last Update Date: 07/01/2024
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 MAIN ST # 228
EL SEGUNDO CA
90245-3803
US

IV. Provider business mailing address

214 MAIN ST # 228
EL SEGUNDO CA
90245-3803
US

V. Phone/Fax

Practice location:
  • Phone: 424-210-5737
  • Fax:
Mailing address:
  • Phone: 424-210-5737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW121041
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103970
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: