Provider Demographics
NPI:1073142725
Name:MILLER, SEAN BRANDON
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:BRANDON
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 1:10179 192ND LN NW
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-0140
Mailing Address - Country:US
Mailing Address - Phone:763-242-5649
Mailing Address - Fax:
Practice Address - Street 1:9201 75TH AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55428-1024
Practice Address - Country:US
Practice Address - Phone:763-315-7173
Practice Address - Fax:763-951-3097
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-05
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304610101YA0400X
MN4364106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)