Healthcare Provider Details

I. General information

NPI: 1053797613
Provider Name (Legal Business Name): JEREMY KEITH MILLER MSW, LISW-S,LICDC-CS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 GLENDALE AVE STE 200
TOLEDO OH
43614-2490
US

IV. Provider business mailing address

3401 GLENDALE AVE STE 200
TOLEDO OH
43614-2490
US

V. Phone/Fax

Practice location:
  • Phone: 567-742-7117
  • Fax: 567-200-8410
Mailing address:
  • Phone: 567-218-1980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.161437
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1700237-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: