Healthcare Provider Details

I. General information

NPI: 1730167537
Provider Name (Legal Business Name): RUSSELL W MILLER MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 12/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2755 STATE ROAD TT
NEW BLOOMFIELD MO
65063-1642
US

IV. Provider business mailing address

2755 STATE ROAD TT
NEW BLOOMFIELD MO
65063-1642
US

V. Phone/Fax

Practice location:
  • Phone: 573-690-4614
  • Fax: 573-896-8956
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2001018057
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2001018057
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2001018057
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2001018057
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: