Healthcare Provider Details

I. General information

NPI: 1922175090
Provider Name (Legal Business Name): MR. ADAM MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5164 BODEGA AVE
PETALUMA CA
94952-7605
US

IV. Provider business mailing address

5164 BODEGA AVE
PETALUMA CA
94952-7605
US

V. Phone/Fax

Practice location:
  • Phone: 415-663-8231
  • Fax:
Mailing address:
  • Phone: 707-789-9691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: