Provider Demographics
NPI:1639989700
Name:MILLER, DE'ANDRE L SR (CD,CHW)
Entity type:Individual
Prefix:
First Name:DE'ANDRE
Middle Name:L
Last Name:MILLER
Suffix:SR
Gender:M
Credentials:CD,CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1918 JERSEY ST
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4643
Mailing Address - Country:US
Mailing Address - Phone:618-606-3748
Mailing Address - Fax:
Practice Address - Street 1:1918 JERSEY ST
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4643
Practice Address - Country:US
Practice Address - Phone:618-606-3748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-10
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO251S00000X
IL374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No251S00000XAgenciesCommunity/Behavioral Health