Basic Information
| Provider Information | |||||||||
| NPI: | 1629051545 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | USA MEDDAC ATTN: CREDENTIALS | ||||||||
| Address2: | 11050 MT BELVEDERE BLVD | ||||||||
| City: | FORT DRUM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136035004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157724025 | ||||||||
| FaxNumber: | 3157744931 | ||||||||
| Practice Location | |||||||||
| Address1: | USA MEDDAC ATTN: CREDENTIALS | ||||||||
| Address2: | 11050 MT BELVEDERE BLVD | ||||||||
| City: | FORT DRUM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136035004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157724025 | ||||||||
| FaxNumber: | 3157744931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 03/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CW013547 | PA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | CW013547 | PA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.