Basic Information
| Provider Information | |||||||||
| NPI: | 1134368020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | LEWIS | ||||||||
| MiddleName: | H, | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2121A BELLEVUE RD | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310212998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782721190 | ||||||||
| FaxNumber: | 4782747628 | ||||||||
| Practice Location | |||||||||
| Address1: | 2121A BELLEVUE RD | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310212998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782721190 | ||||||||
| FaxNumber: | 4782747628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2009 | ||||||||
| LastUpdateDate: | 04/02/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | APC001412 | GA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101Y00000X | LPC005725 | GA | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 300030912A | 05 | GA | MEDICAID | 000606284H | 05 | GA | MEDICAID | 582109771 | 01 | GA | FACILITY | OTHER |