Provider Demographics
NPI:1033234927
Name:MILLER, MARK CLENDENEN
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:CLENDENEN
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 GREAT OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95119-1314
Mailing Address - Country:US
Mailing Address - Phone:408-281-0708
Mailing Address - Fax:
Practice Address - Street 1:90 GREAT OAKS BLVD
Practice Address - Street 2:108
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119-1314
Practice Address - Country:US
Practice Address - Phone:408-281-0708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC15474106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC15070OtherMFT