Healthcare Provider Details

I. General information

NPI: 1679203574
Provider Name (Legal Business Name): ANGELA MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 COSHOCTON AVE
MOUNT VERNON OH
43050-2634
US

IV. Provider business mailing address

408 COSHOCTON AVE
MOUNT VERNON OH
43050-2634
US

V. Phone/Fax

Practice location:
  • Phone: 740-326-9255
  • Fax:
Mailing address:
  • Phone: 740-326-9255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA180861
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: