Provider Demographics
NPI:1972758753
Name:MILLER, MARK JAY (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:JAY
Last Name:MILLER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 DELLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-2069
Mailing Address - Country:US
Mailing Address - Phone:541-729-4074
Mailing Address - Fax:
Practice Address - Street 1:3003 WILLAMETTE ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97405-3241
Practice Address - Country:US
Practice Address - Phone:541-729-4074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-20
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL002041101Y00000X, 101YA0400X, 101YP2500X, 1041C0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist