Basic Information
| Provider Information | |||||||||
| NPI: | 1518485630 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | MARLON | ||||||||
| MiddleName: | O | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILLER | ||||||||
| OtherFirstName: | MARLON | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1911 WILLIAMS DR STE 165 | ||||||||
| Address2: | |||||||||
| City: | OXNARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930362612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059814233 | ||||||||
| FaxNumber: | 8059819268 | ||||||||
| Practice Location | |||||||||
| Address1: | 1911 WILLIAMS DR STE 165 | ||||||||
| Address2: | |||||||||
| City: | OXNARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930362612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059814233 | ||||||||
| FaxNumber: | 8059819268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2017 | ||||||||
| LastUpdateDate: | 07/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/02/2018 | ||||||||
| NPIReactivationDate: | 06/21/2019 | ||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 95114 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.