Provider Demographics
NPI:1144796178
Name:MILLER, BRANDON SCOTT
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:SCOTT
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:PO BOX 268
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:OR
Mailing Address - Zip Code:97828-0268
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:213 BROADMORE ST
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:OR
Practice Address - Zip Code:97828-1216
Practice Address - Country:US
Practice Address - Phone:541-398-8188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22-06-10445101YA0400X
ORL11633101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)