Provider Demographics
NPI:1295299634
Name:MILLER, MARCUS (MA)
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-3421
Mailing Address - Country:US
Mailing Address - Phone:636-466-4210
Mailing Address - Fax:314-344-6194
Practice Address - Street 1:500 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3421
Practice Address - Country:US
Practice Address - Phone:314-344-6700
Practice Address - Fax:314-344-6194
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431343281Medicaid
MO1033541347Medicaid