Healthcare Provider Details

I. General information

NPI: 1982738142
Provider Name (Legal Business Name): DAVID C. MILLER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 DOUGLAS AVE
LAS VEGAS NM
87701-3928
US

IV. Provider business mailing address

559 VEGAS DR
LAS VEGAS NM
87701-4690
US

V. Phone/Fax

Practice location:
  • Phone: 505-454-5700
  • Fax: 505-454-5702
Mailing address:
  • Phone: 505-425-0158
  • Fax: 505-454-5702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number265261
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: