Healthcare Provider Details

I. General information

NPI: 1295236123
Provider Name (Legal Business Name): WENDELL DAVE MILLER LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2018
Last Update Date: 07/18/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 PETER CT
SOUTH HUNTINGTON NY
11746-4501
US

IV. Provider business mailing address

66 PRIMROSE LN
KINGS PARK NY
11754
US

V. Phone/Fax

Practice location:
  • Phone: 631-748-7730
  • Fax:
Mailing address:
  • Phone: 631-748-7730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8413
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number007714
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number127312
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: