Provider Demographics
NPI:1770379349
Name:MILLER, MARK SHERWOOD (LPC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:SHERWOOD
Last Name:MILLER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 EASTVOLD AVE
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56278-1133
Mailing Address - Country:US
Mailing Address - Phone:320-839-4067
Mailing Address - Fax:
Practice Address - Street 1:450 EASTVOLD AVE
Practice Address - Street 2:
Practice Address - City:ORTONVILLE
Practice Address - State:MN
Practice Address - Zip Code:56278-1133
Practice Address - Country:US
Practice Address - Phone:320-839-4067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-18
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3118101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional