Healthcare Provider Details

I. General information

NPI: 1164331369
Provider Name (Legal Business Name): MR. CHUCK MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35600 BENTLEY DR
AVON OH
44011-3806
US

IV. Provider business mailing address

35600 BENTLEY DR
AVON OH
44011-3806
US

V. Phone/Fax

Practice location:
  • Phone: 440-937-4680
  • Fax:
Mailing address:
  • Phone: 440-937-4680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLSP.00888
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: