MEDICARE: DAVINA MARION MILLER M.S.W., L.I.C.S.W.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1015419	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1857304	OTHER	MA	MASS HEALTH B
2	407882	OTHER	MA	TUFTS HEALTH CARE
3	P04729	OTHER	MA	BLUE CROSS AND BLUE SHIEL

General Provider Information

NPI Number	:	1477608776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVINA MARION MILLER M.S.W., L.I.C.S.W.

Provider Business Mailing Address
First Line	:	57 GOTHIC ST
Second Line	:
City	:	NORTHAMPTON
State	:	MA
Zip	:	01060-3047
Country	:	US
Telephone Number	:	413-584-1992
Fax Number	:	413-584-1166

Provider Business Practice Location Address
First Line	:	57 GOTHIC ST
Second Line	:
City	:	NORTHAMPTON
State	:	MA
Zip	:	01060-3047
Country	:	US
Telephone Number	:	413-584-1992
Fax Number	:	413-584-1166

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	07/08/2007

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