Healthcare Provider Details

I. General information

NPI: 1508855420
Provider Name (Legal Business Name): TINA MILLER MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E JEFFERSON BLVD SUITE 700
SOUTH BEND IN
46601-1922
US

IV. Provider business mailing address

105 E JEFFERSON BLVD SUITE 700
SOUTH BEND IN
46601-1922
US

V. Phone/Fax

Practice location:
  • Phone: 574-232-2255
  • Fax: 574-287-9377
Mailing address:
  • Phone: 574-232-2255
  • Fax: 574-287-9377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: