MEDICARE: MS. CONSTANCE MILLER GARRY LCPC

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	101YP2500X	Professional Counselor		IL

General Provider Information

NPI Number	:	1639153588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CONSTANCE MILLER GARRY LCPC

Provider Business Mailing Address
First Line	:	908 RIDGEWOOD RD
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61107-3054
Country	:	US
Telephone Number	:	815-965-8423
Fax Number	:

Provider Business Practice Location Address
First Line	:	1601 PARKVIEW AVE
Second Line	:	UNIVERSITY PSYCHIATRIC SERVICES
City	:	ROCKFORD
State	:	IL
Zip	:	61107-1822
Country	:	US
Telephone Number	:	815-395-5870
Fax Number	:	815-395-5750

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

Provider Enumeration Date	:	12/05/2005
Last Update Date	:	07/08/2007

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