Provider Demographics
NPI:1912013392
Name:MILLER, MARK E (LIMHP, LISW, LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:E
Last Name:MILLER
Suffix:
Gender:M
Credentials:LIMHP, LISW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12035 Q STREET
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-3542
Mailing Address - Country:US
Mailing Address - Phone:402-991-0611
Mailing Address - Fax:402-991-6228
Practice Address - Street 1:12035 Q STREET
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-3542
Practice Address - Country:US
Practice Address - Phone:402-991-0611
Practice Address - Fax:402-991-6228
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA067561041C0700X
NE14131041C0700X, 1041C0700X
NE1199101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIB158001OtherMEDICARE PTAN
IAIB158001OtherMEDICARE PTAN