Healthcare Provider Details

I. General information

NPI: 1518762756
Provider Name (Legal Business Name): MARY ELLEN MILLER, MS, LPC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2025
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W10445 STATE ROAD 16 LOT 21
PORTAGE WI
53901-9488
US

IV. Provider business mailing address

W10445 STATE ROAD 16 LOT 21
PORTAGE WI
53901-9488
US

V. Phone/Fax

Practice location:
  • Phone: 608-617-8419
  • Fax:
Mailing address:
  • Phone: 608-617-8419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MS. MARY ELLEN ELLEN MILLER MS MILLER
Title or Position: DIRECTOR
Credential: LPC
Phone: 608-617-8419