Provider Demographics
NPI:1255940599
Name:MILLER, BRANDON KEITH (LSW)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:KEITH
Last Name:MILLER
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 COMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-7353
Mailing Address - Country:US
Mailing Address - Phone:331-425-5283
Mailing Address - Fax:
Practice Address - Street 1:309 W CLARK ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-4637
Practice Address - Country:US
Practice Address - Phone:217-398-9066
Practice Address - Fax:217-398-9077
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.104394104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker