Provider Demographics
NPI:1518446640
Name:MILLER, DEAN (LMSW, MSCJ)
Entity Type:Individual
Prefix:MR
First Name:DEAN
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:LMSW, MSCJ
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 E BENNETT ST STE H
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-1425
Mailing Address - Country:US
Mailing Address - Phone:417-942-0005
Mailing Address - Fax:417-942-5772
Practice Address - Street 1:1925 E BENNETT ST STE H
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1425
Practice Address - Country:US
Practice Address - Phone:417-942-0005
Practice Address - Fax:417-942-5772
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-09
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019042627104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO82-4788009Medicaid