MEDICARE: SUSAN LUCY MILLER

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	329431	NM

General Provider Information

NPI Number	:	1558517169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN LUCY MILLER

Provider Business Mailing Address
First Line	:	729 SAN DIEGO LOOP
Second Line	:
City	:	JEMEZ SPRINGS
State	:	NM
Zip	:	87025
Country	:	US
Telephone Number	:	575-829-4526
Fax Number	:

Provider Business Practice Location Address
First Line	:	729 SAN DIEGO LOOP
Second Line	:
City	:	JEMEZ SPRINGS
State	:	NM
Zip	:	87025
Country	:	US
Telephone Number	:	575-829-4526
Fax Number	:

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

Provider Enumeration Date	:	08/14/2008
Last Update Date	:	08/14/2008

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