Healthcare Provider Details

I. General information

NPI: 1528694643
Provider Name (Legal Business Name): TIMOTHY MICHAEL MILLER LSW, LICDC-S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2020
Last Update Date: 07/21/2022
Certification Date: 03/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 PHALE D. HALE DR.
COLUMBUS OH
43203
US

IV. Provider business mailing address

11122 GORSUCH RD
GALENA OH
43021-9633
US

V. Phone/Fax

Practice location:
  • Phone: 614-257-3754
  • Fax:
Mailing address:
  • Phone: 419-203-9314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number001104
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: