Healthcare Provider Details

I. General information

NPI: 1861122186
Provider Name (Legal Business Name): GENNELL MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2022
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1247 GREYSTONE RD
HALETHORPE MD
21227-2302
US

IV. Provider business mailing address

1247 GREYSTONE RD
HALETHORPE MD
21227-2302
US

V. Phone/Fax

Practice location:
  • Phone: 301-706-2333
  • Fax:
Mailing address:
  • Phone: 301-706-2333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC200003495
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number0904018885
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number28564
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: