Provider Demographics
NPI:1508119728
Name:MILLER, MARY H (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:H
Last Name:MILLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:453 YOUNGSDALE DR
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-7380
Mailing Address - Country:US
Mailing Address - Phone:707-290-6125
Mailing Address - Fax:707-447-4245
Practice Address - Street 1:351 TRAVIS AVENUE BUILDING 660
Practice Address - Street 2:
Practice Address - City:TRAVIS AIR FORCE BASE
Practice Address - State:CA
Practice Address - Zip Code:94535
Practice Address - Country:US
Practice Address - Phone:707-424-2486
Practice Address - Fax:707-447-4245
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE15561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical