Provider Demographics
NPI:1255395380
Name:MILLER, TOMMIE L (LCSW)
Entity type:Individual
Prefix:
First Name:TOMMIE
Middle Name:L
Last Name:MILLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 KEMP DR
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-9607
Mailing Address - Country:US
Mailing Address - Phone:417-326-2579
Mailing Address - Fax:417-326-2579
Practice Address - Street 1:1209 KEMP DR
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-9607
Practice Address - Country:US
Practice Address - Phone:417-326-2579
Practice Address - Fax:417-326-2579
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040154881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499356806Medicaid
MO195860OtherBLUECROSS BLUE SHIELD ID
MO824773424Medicare PIN
MO824774549Medicare PIN