Basic Information
| Provider Information | |||||||||
| NPI: | 1003162314 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | BENJAMIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 888 W BONNEVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891060100 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 888 W BONNEVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891060100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024836000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2012 | ||||||||
| LastUpdateDate: | 03/30/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 701 | NV | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103G00000X | 25703 | CA | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.