Provider Demographics
NPI:1104902220
Name:MILLER, MINDY JANE (LCSW)
Entity type:Individual
Prefix:MS
First Name:MINDY
Middle Name:JANE
Last Name:MILLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 E 20TH ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-0928
Mailing Address - Country:US
Mailing Address - Phone:417-627-9601
Mailing Address - Fax:
Practice Address - Street 1:1505 E 20TH ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-0928
Practice Address - Country:US
Practice Address - Phone:417-627-9601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040243821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical