Healthcare Provider Details

I. General information

NPI: 1104470640
Provider Name (Legal Business Name): CARRIE ANN MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2019
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 LANSING AVE
JACKSON MI
49202
US

IV. Provider business mailing address

5311 BROOKLYN ROAD APARTMENT 10
JACKSON MI
49201
US

V. Phone/Fax

Practice location:
  • Phone: 517-784-2929
  • Fax:
Mailing address:
  • Phone: 304-377-4528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801105296
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: