Provider Demographics
NPI:1053663799
Name:MILLER, GARY A (LCSW)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:MILLER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10700
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-5517
Mailing Address - Country:US
Mailing Address - Phone:970-242-5707
Mailing Address - Fax:970-242-7245
Practice Address - Street 1:3150 N 12TH ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-2863
Practice Address - Country:US
Practice Address - Phone:970-242-5707
Practice Address - Fax:970-242-7245
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-04
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9891781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical