Healthcare Provider Details

I. General information

NPI: 1629051545
Provider Name (Legal Business Name): JAMES RICHARD MILLER MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 03/08/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USA MEDDAC ATTN: CREDENTIALS 11050 MT BELVEDERE BLVD
FORT DRUM NY
13603-5004
US

IV. Provider business mailing address

USA MEDDAC ATTN: CREDENTIALS 11050 MT BELVEDERE BLVD
FORT DRUM NY
13603-5004
US

V. Phone/Fax

Practice location:
  • Phone: 315-772-4025
  • Fax: 315-774-4931
Mailing address:
  • Phone: 315-772-4025
  • Fax: 315-774-4931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW013547
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberCW013547
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: