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General NPI Number Information
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NPI Number | 1154410777
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Entity Type | Individual
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Provider Name | MARK EDISON MILLER SOCIAL WORKER
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Gender | Male
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Dates
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Enumeration Date | 10/12/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1481 W 10TH ST
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City | INDIANAPOLIS
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State | IN
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Zip | 46202-2803
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Country | US
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Telephone | 317-988-2501
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Fax | 317-988-3243
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Provider Business Mailing Address
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Address Line | 3440 E FALL CREEK PARKWAY NORTH DR
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City | INDIANAPOLIS
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State | IN
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Zip | 46205-3693
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Country | US
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Telephone | 317-283-9042
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Fax | 317-988-3243
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 34003626A
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License Number State | IN
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