Provider Demographics
NPI:1942373956
Name:MILLER, MARK JOHN (LPCC LADAC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:JOHN
Last Name:MILLER
Suffix:
Gender:M
Credentials:LPCC LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 S LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001
Mailing Address - Country:US
Mailing Address - Phone:575-522-6944
Mailing Address - Fax:575-522-7901
Practice Address - Street 1:1800 S LOCUST ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001
Practice Address - Country:US
Practice Address - Phone:575-522-6944
Practice Address - Fax:575-522-7901
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM005708101YA0400X
NM0076621101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)