Provider Demographics
NPI:1295150837
Name:MILLER, MICHAEL A (CADC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:MILLER
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2619 WARD AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERBANK
Mailing Address - State:CA
Mailing Address - Zip Code:95367-2718
Mailing Address - Country:US
Mailing Address - Phone:209-622-8516
Mailing Address - Fax:
Practice Address - Street 1:800 SCENIC DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6131
Practice Address - Country:US
Practice Address - Phone:209-525-6150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-19
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CAC10261214101YA0400X, 372600000X
MPSS-DPKVHU175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult Companion
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17500000XMedicaid