Provider Demographics
NPI:1508849159
Name:MILLER, MINDY SUE (MSW CSW)
Entity Type:Individual
Prefix:MRS
First Name:MINDY
Middle Name:SUE
Last Name:MILLER
Suffix:
Gender:F
Credentials:MSW CSW
Other - Prefix:
Other - First Name:MINDY
Other - Middle Name:SUE
Other - Last Name:HARES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:307 S FRONT ST STE 115
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4610
Mailing Address - Country:US
Mailing Address - Phone:906-273-2507
Mailing Address - Fax:906-273-2507
Practice Address - Street 1:148 W WASHINGTON ST STE A
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4383
Practice Address - Country:US
Practice Address - Phone:906-273-2507
Practice Address - Fax:906-273-2507
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2022-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010716501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1508849159Medicaid
MI0E26040035Medicare PIN