Healthcare Provider Details

I. General information

NPI: 1407900103
Provider Name (Legal Business Name): TANISHA MILLER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 E 149TH ST SOCIAL WORK OFFICE ROOM 1B2
BRONX NY
10451-5504
US

IV. Provider business mailing address

2999 FREDERICK DOUGLASS BLVD #25K
NEW YORK NY
10039-1320
US

V. Phone/Fax

Practice location:
  • Phone: 718-579-5657
  • Fax:
Mailing address:
  • Phone: 917-539-3563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number072986
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: