Provider Demographics
NPI:1932129327
Name:MILLER, GARY MICHAEL
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:MICHAEL
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43409 BREWSTER CT
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-4315
Mailing Address - Country:US
Mailing Address - Phone:951-303-2166
Mailing Address - Fax:
Practice Address - Street 1:523 HAYES LN
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-4011
Practice Address - Country:US
Practice Address - Phone:800-257-8715
Practice Address - Fax:800-819-1655
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15695103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY156950OtherRIVERSIDE COUNTY
CA0PL156950OtherBLUE CROSS BLUE SHIELD
CAPSY156950Medicaid
CAPSY156950Medicaid