Provider Demographics
NPI:1164526752
Name:MILLER, LARRY EUGENE (MSW)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:EUGENE
Last Name:MILLER
Suffix:
Gender:M
Credentials:MSW
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 500938
Mailing Address - Street 2:
Mailing Address - City:SAIPAN
Mailing Address - State:MP
Mailing Address - Zip Code:96950-0938
Mailing Address - Country:US
Mailing Address - Phone:670-322-0035
Mailing Address - Fax:
Practice Address - Street 1:MH II BUILDING, MARINA HEIGHTS BUSINESS PARK
Practice Address - Street 2:SUITE 206
Practice Address - City:SAIPAN
Practice Address - State:MP
Practice Address - Zip Code:96950
Practice Address - Country:US
Practice Address - Phone:670-322-0035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR022061-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIVAD000Medicare UPIN