Healthcare Provider Details

I. General information

NPI: 1679557664
Provider Name (Legal Business Name): JILL BLUM MILLIS MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 STERLING ST
WEST NEWTON MA
02465-2635
US

IV. Provider business mailing address

70 STERLING ST
WEST NEWTON MA
02465-2635
US

V. Phone/Fax

Practice location:
  • Phone: 617-527-7188
  • Fax:
Mailing address:
  • Phone: 617-527-7188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number102273
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: