Provider Demographics
NPI:1063400067
Name:MILLER, CECIL M (PHD)
Entity type:Individual
Prefix:
First Name:CECIL
Middle Name:M
Last Name:MILLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MESSIMER DR
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1842
Mailing Address - Country:US
Mailing Address - Phone:740-522-2230
Mailing Address - Fax:740-522-6230
Practice Address - Street 1:60 MESSIMER DR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1842
Practice Address - Country:US
Practice Address - Phone:740-522-2230
Practice Address - Fax:740-522-6230
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4362103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R56807Medicare UPIN
OHMICP07572Medicare ID - Type Unspecified