Provider Demographics
NPI:1174643738
Name:MILLER, JOHN CLARK (LCSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CLARK
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:PO BOX 146
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97136-0146
Mailing Address - Country:US
Mailing Address - Phone:541-377-1631
Mailing Address - Fax:971-606-2001
Practice Address - Street 1:60 LANEDA AVENUE
Practice Address - Street 2:SUITE 202
Practice Address - City:MANZANITA
Practice Address - State:OR
Practice Address - Zip Code:97130-0000
Practice Address - Country:US
Practice Address - Phone:971-324-0061
Practice Address - Fax:971-606-2001
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12-03-71101YA0400X
ORL54611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500671647Medicaid
OR500671647Medicaid