Provider Demographics
NPI:1184817900
Name:MILLER, LEONARD EZEKIEL (PSYD, HSPP)
Entity type:Individual
Prefix:
First Name:LEONARD
Middle Name:EZEKIEL
Last Name:MILLER
Suffix:
Gender:M
Credentials:PSYD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47265-1510
Mailing Address - Country:US
Mailing Address - Phone:812-346-2872
Mailing Address - Fax:812-346-4172
Practice Address - Street 1:257 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH VERNON
Practice Address - State:IN
Practice Address - Zip Code:47265-1510
Practice Address - Country:US
Practice Address - Phone:812-346-2872
Practice Address - Fax:812-346-4172
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040350A103T00000X
KYKY-0594103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200147420AMedicaid
IN211650BMedicare PIN