Provider Demographics
NPI:1831295179
Name:MILLER, CLYDE KERMIT II (MS, MSW)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:KERMIT
Last Name:MILLER
Suffix:II
Gender:M
Credentials:MS, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10163 SE SUNNYSIDE RD, STE 490
Mailing Address - Street 2:KAISER PERMANENTE ONE TOWN CENTER
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-9746
Mailing Address - Country:US
Mailing Address - Phone:503-513-4400
Mailing Address - Fax:
Practice Address - Street 1:10163 SE SUNNYSIDE RD
Practice Address - Street 2:STE.490
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5743
Practice Address - Country:US
Practice Address - Phone:503-513-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0013741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical