Provider Demographics
NPI:1568649416
Name:MILLER, NICOLE M (LCSW)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:M
Last Name:MILLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1276 FULTON AVE
Mailing Address - Street 2:CPEP/MCT
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-3402
Mailing Address - Country:US
Mailing Address - Phone:718-901-8870
Mailing Address - Fax:718-901-8864
Practice Address - Street 1:1276 FULTON AVE
Practice Address - Street 2:CPEP/MCT
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-3402
Practice Address - Country:US
Practice Address - Phone:718-901-8870
Practice Address - Fax:718-901-8864
Is Sole Proprietor?:No
Enumeration Date:2008-01-23
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY074218-1104100000X
VA09040069251041C0700X
NY0788331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01079267Medicaid