Basic Information
| Provider Information | |||||||||
| NPI: | 1477628931 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | JEFFRY | ||||||||
| MiddleName: | LOYD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MS LCSW LMFT LPC CAD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 128 E OLIN AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082521320 | ||||||||
| FaxNumber: | 6082521333 | ||||||||
| Practice Location | |||||||||
| Address1: | 128 E OLIN AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082521320 | ||||||||
| FaxNumber: | 6082521333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 06/17/2009 | ||||||||
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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 | 101YA0400X | 1659 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 713 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 1041C0700X | 3220 | WI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | 400 | WI | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 39302200 | 05 | WI | MEDICAID |