Basic Information
| Provider Information | |||||||||
| NPI: | 1821279746 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MA LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 S JONES | ||||||||
| Address2: | CUSHING VALLEY HOPE | ||||||||
| City: | CUSHING | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182251736 | ||||||||
| FaxNumber: | 9182257742 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 S JONES | ||||||||
| Address2: | CUSHING VALLEY HOPE | ||||||||
| City: | CUSHING | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182251736 | ||||||||
| FaxNumber: | 9182257742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2007 | ||||||||
| LastUpdateDate: | 11/20/2007 | ||||||||
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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 | LADC 612 | OK | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 612 | 01 | OK | LADC ALCOHOL & DRUG COUNS | OTHER |