Provider Demographics
NPI:1164089074
Name:MILLER, RYAN (LCSW)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
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 1:1054 HUCKLEBERRY CIR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:UT
Mailing Address - Zip Code:84653-5691
Mailing Address - Country:US
Mailing Address - Phone:801-234-0653
Mailing Address - Fax:
Practice Address - Street 1:5455 RIVER RUN DR
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-7726
Practice Address - Country:US
Practice Address - Phone:801-234-0653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-26
Last Update Date:2019-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6607196-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical