Healthcare Provider Details

I. General information

NPI: 1417464470
Provider Name (Legal Business Name): CASSAUNDRA ELYZABETH MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2017
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2775 STATE ROUTE 39
SHELBY OH
44875-9466
US

IV. Provider business mailing address

20 MYRTLE DR
SHELBY OH
44875-1805
US

V. Phone/Fax

Practice location:
  • Phone: 419-747-3322
  • Fax:
Mailing address:
  • Phone: 567-303-2435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.186261
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2410517
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: