Basic Information
| Provider Information | |||||||||
| NPI: | 1386243608 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | ELIAS | ||||||||
| MiddleName: | JABREEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3430 WIZARD AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402152749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5027770657 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1700 CARGO CT | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402991938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5027496764 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2020 | ||||||||
| LastUpdateDate: | 10/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 251932 | KY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.