Basic Information
| Provider Information | |||||||||
| NPI: | 1477705218 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | SHERRY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | M.S., LPC, LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4327 E WINNESHIEK RD | ||||||||
| Address2: | |||||||||
| City: | FREEPORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610328217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9154843854 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1969 W HART RD | ||||||||
| Address2: | |||||||||
| City: | BELOIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535112230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083645686 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2008 | ||||||||
| LastUpdateDate: | 07/27/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 649 | OK | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | 15681-132 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 4869-125 | WI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 4354 | OK | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 4773 | OK | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 200231200A | 05 | OK | MEDICAID | 100027401 | 05 | WI | MEDICAID |