Healthcare Provider Details

I. General information

NPI: 1689410110
Provider Name (Legal Business Name): SEVONTE H MILLER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2024
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7960 N WICKHAM RD STE 101
MELBOURNE FL
32940-8096
US

IV. Provider business mailing address

950 CROSS LAKE DR
MELBOURNE FL
32901-8467
US

V. Phone/Fax

Practice location:
  • Phone: 321-504-8766
  • Fax:
Mailing address:
  • Phone: 321-830-5284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW23097
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: