=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811347974
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA ANN MILLER LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2016
-----------------------------------------------------
Last Update Date | 01/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | EMERALD COAST BEHAVIORAL HOSPITAL OUTPATIENT CLINIC 1940 HARRISON AVE
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-481-0306
-----------------------------------------------------
Fax | 850-481-0309
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 492 CHAMPLAIN CT
-----------------------------------------------------
City | BELLE RIVER
-----------------------------------------------------
State | ON
-----------------------------------------------------
Zip | N0R1A0
-----------------------------------------------------
Country | CA
-----------------------------------------------------
Telephone | 956-536-6655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801099319
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW20512
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------