Provider Demographics
NPI:1285861666
Name:MILLER, JOHN LAURENCE (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LAURENCE
Last Name:MILLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 W 27TH ST
Mailing Address - Street 2:3R
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-6235
Mailing Address - Country:US
Mailing Address - Phone:212-645-8780
Mailing Address - Fax:212-645-8780
Practice Address - Street 1:144 W 27TH ST
Practice Address - Street 2:3R
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-6214
Practice Address - Country:US
Practice Address - Phone:212-645-8780
Practice Address - Fax:212-645-8780
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-12
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014068103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYO3113384Medicaid
A400014124Medicare PIN