Provider Demographics
NPI:1447767058
Name:MILLER, SOPHIE JETTA (LCSW-R)
Entity Type:Individual
Prefix:
First Name:SOPHIE
Middle Name:JETTA
Last Name:MILLER
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 W 140TH ST APT 43
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-6118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:507 WEST 140TH STREET
Practice Address - Street 2:#43
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031
Practice Address - Country:US
Practice Address - Phone:917-690-2118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-04
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0522281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical