Provider Demographics
NPI:1629614789
Name:MILLER, GENNA (MA, LCAS-R)
Entity Type:Individual
Prefix:
First Name:GENNA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:MA, LCAS-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4704 COUNTRY CLUB DR N
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27896-9116
Mailing Address - Country:US
Mailing Address - Phone:315-256-3378
Mailing Address - Fax:
Practice Address - Street 1:7540 RAMBLE WAY STE 109
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-4318
Practice Address - Country:US
Practice Address - Phone:252-281-2515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-25
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-25948101YA0400X
NCA16834101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)