Provider Demographics
NPI:1578632287
Name:MILLER, AUDREY BARBARA (LCSWR)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:BARBARA
Last Name:MILLER
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 E 2ND ST STE 105
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-4686
Mailing Address - Country:US
Mailing Address - Phone:631-369-8310
Mailing Address - Fax:631-369-8310
Practice Address - Street 1:21 E 2ND ST STE 105
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-4686
Practice Address - Country:US
Practice Address - Phone:631-369-8310
Practice Address - Fax:631-369-8310
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR055802-11041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY270174000OtherMAGELLAN
NYND740OtherEMPIRE BC BS
NY247701OtherVALUE OPTIONS
NY7043026OtherAETNA
NYND7401Medicare ID - Type Unspecified