Provider Demographics
NPI:1619992757
Name:MILLER, ANDREW JAMES (PSYD, HSPP)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JAMES
Last Name:MILLER
Suffix:
Gender:M
Credentials:PSYD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 ALABAMA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5011
Mailing Address - Country:US
Mailing Address - Phone:260-373-0880
Mailing Address - Fax:260-373-0881
Practice Address - Street 1:12948 COLDWATER RD STE 101
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-8016
Practice Address - Country:US
Practice Address - Phone:260-373-0880
Practice Address - Fax:260-373-0881
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001777A101YM0800X
IN20042470A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201010850Medicaid