Healthcare Provider Details

I. General information

NPI: 1477801793
Provider Name (Legal Business Name): BRIAN EDWARD MILLER LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 08/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 CARLISLE BLVD NE SUITE B
ALBUQUERQUE NM
87110-5658
US

IV. Provider business mailing address

1400 CARLISLE BLVD NE SUITE B
ALBUQUERQUE NM
87110-5658
US

V. Phone/Fax

Practice location:
  • Phone: 505-271-6630
  • Fax: 505-271-6442
Mailing address:
  • Phone: 505-271-6630
  • Fax: 505-271-6442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0151561
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0151561
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: