Provider Demographics
NPI:1144232588
Name:MILLER, BETTY JO (LCSW)
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:JO
Last Name:MILLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 PAVILION DR
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4622
Mailing Address - Country:US
Mailing Address - Phone:423-857-5571
Mailing Address - Fax:423-857-5237
Practice Address - Street 1:2300 PAVILION DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4622
Practice Address - Country:US
Practice Address - Phone:423-857-5571
Practice Address - Fax:423-857-5237
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN42481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3926661Medicare ID - Type Unspecified