Provider Demographics
NPI:1790351674
Name:MILLER, CARLY JANELL (LCSW)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:JANELL
Last Name:MILLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1848 W GRACE ST APT 1R
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2765
Mailing Address - Country:US
Mailing Address - Phone:312-384-9141
Mailing Address - Fax:
Practice Address - Street 1:2418 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2940
Practice Address - Country:US
Practice Address - Phone:312-666-3494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1501049521041C0700X
IL24584081041S0200X
IL1490252031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool