Healthcare Provider Details

I. General information

NPI: 1932063948
Provider Name (Legal Business Name): MARCELLUS MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2025
Last Update Date: 12/13/2025
Certification Date: 12/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14724 VENTURA BLVD STE 1105
SHERMAN OAKS CA
91403-3510
US

IV. Provider business mailing address

1756 W AVENUE J12 APT 103C
LANCASTER CA
93534-4654
US

V. Phone/Fax

Practice location:
  • Phone: 747-298-3463
  • Fax:
Mailing address:
  • Phone: 661-470-9721
  • Fax: 661-470-9721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: