Provider Demographics
NPI:1346207677
Name:MILLER, MARTHA J (LISW)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:J
Last Name:MILLER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 KENYON RD
Mailing Address - Street 2:STE A
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501
Mailing Address - Country:US
Mailing Address - Phone:515-574-6120
Mailing Address - Fax:515-574-6135
Practice Address - Street 1:804 KENYON RD
Practice Address - Street 2:STE A
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501
Practice Address - Country:US
Practice Address - Phone:515-574-6120
Practice Address - Fax:515-574-6135
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA020391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
10198OtherBCBS
7298OtherMIDLANDS CHOICE
IA0218438Medicaid
IA0218438Medicaid