Provider Demographics
NPI:1770659815
Name:MILLER, MARY ELLEN (LPC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELLEN
Last Name:MILLER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 N BLACKHAWK AVE
Mailing Address - Street 2:SUITE205
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3357
Mailing Address - Country:US
Mailing Address - Phone:608-233-3037
Mailing Address - Fax:608-233-5893
Practice Address - Street 1:702 N BLACKHAWK AVE
Practice Address - Street 2:SUITE205
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3357
Practice Address - Country:US
Practice Address - Phone:608-233-3037
Practice Address - Fax:608-233-5893
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2321-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39206700Medicaid