Healthcare Provider Details

I. General information

NPI: 1295889814
Provider Name (Legal Business Name): LAUREN MILLER PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 12/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E SUPERIOR ST STE 300
CHICAGO IL
60611-2507
US

IV. Provider business mailing address

5825 S BLACKSTONE AVE
CHICAGO IL
60637-5203
US

V. Phone/Fax

Practice location:
  • Phone: 312-475-0505
  • Fax: 312-475-0551
Mailing address:
  • Phone: 312-245-9910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071-006440
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: