Healthcare Provider Details

I. General information

NPI: 1487945556
Provider Name (Legal Business Name): MARK MILLER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2011
Last Update Date: 08/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1965 LIVE OAK BLVD
YUBA CITY CA
95991-8850
US

IV. Provider business mailing address

PO BOX 9063
BEALE AFB CA
95903-9063
US

V. Phone/Fax

Practice location:
  • Phone: 530-822-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW78085
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: