Healthcare Provider Details

I. General information

NPI: 1821101551
Provider Name (Legal Business Name): EDWIN LEE MILLER JR. MDIV MHR LPC LMFT LA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5208 CLASSEN CIR
OKLAHOMA CITY OK
73118-4429
US

IV. Provider business mailing address

3300 N VERMONT AVE
OKLAHOMA CITY OK
73112-3133
US

V. Phone/Fax

Practice location:
  • Phone: 405-848-2370
  • Fax: 405-810-0331
Mailing address:
  • Phone: 405-823-5608
  • Fax: 405-810-0331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number96
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number00
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1424
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number714
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: