Provider Demographics
NPI:1356431134
Name:MILLER, CONARD MARK (LCSW)
Entity type:Individual
Prefix:MR
First Name:CONARD
Middle Name:MARK
Last Name:MILLER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 W 23RD ST
Mailing Address - Street 2:7B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-2435
Mailing Address - Country:US
Mailing Address - Phone:917-817-3843
Mailing Address - Fax:
Practice Address - Street 1:115 CHARLES ST
Practice Address - Street 2:WEST BASEMENT
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10014-2514
Practice Address - Country:US
Practice Address - Phone:917-817-3843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY076559104100000X
NY0778421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300093618Medicare PIN