Healthcare Provider Details

I. General information

NPI: 1619458619
Provider Name (Legal Business Name): DAVID JOHN MILLER II LCSW-A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 02/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 SIGNAL HILL DRIVE EXT
STATESVILLE NC
28625-4391
US

IV. Provider business mailing address

284 EXECUTIVE PARK DR STE 100
CONCORD NC
28025-1833
US

V. Phone/Fax

Practice location:
  • Phone: 704-871-1045
  • Fax: 704-873-6647
Mailing address:
  • Phone: 704-939-1100
  • Fax: 704-939-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP012677
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: