Provider Demographics
NPI:1699849372
Name:MILLER, LARRY JACK (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:JACK
Last Name:MILLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 SPICEWOOD SPRINGS RD
Mailing Address - Street 2:SUITE K-8
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8661
Mailing Address - Country:US
Mailing Address - Phone:512-502-1882
Mailing Address - Fax:502-346-4188
Practice Address - Street 1:4131 SPICEWOOD SPRINGS RD
Practice Address - Street 2:SUITE K-8
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8661
Practice Address - Country:US
Practice Address - Phone:512-502-1882
Practice Address - Fax:502-346-4188
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2 1851101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXGK 72OtherBLUE CROSS BLUE SHIELD
TX00939YMedicare ID - Type Unspecified