Healthcare Provider Details

I. General information

NPI: 1114460003
Provider Name (Legal Business Name): DOUGLAS MILLER JR. MS.ED SCHOOL PSYCHOL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2016
Last Update Date: 11/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

379 MT HOPE RD
MIDDLETOWN NY
10940-7135
US

IV. Provider business mailing address

379 MT HOPE RD
MIDDLETOWN NY
10940
US

V. Phone/Fax

Practice location:
  • Phone: 845-344-2292
  • Fax: 845-342-2054
Mailing address:
  • Phone: 845-344-2292
  • Fax: 845-342-2054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number156033021
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: