Provider Demographics
NPI:1114035144
Name:MILLER, LAURENCE ALBERT (PHD)
Entity type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:ALBERT
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 1:1491 HOPKINS ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94702-1244
Mailing Address - Country:US
Mailing Address - Phone:415-235-6311
Mailing Address - Fax:510-558-3138
Practice Address - Street 1:1491 HOPKINS ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94702-1244
Practice Address - Country:US
Practice Address - Phone:415-235-6311
Practice Address - Fax:510-558-3138
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18163103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL181630Medicare ID - Type UnspecifiedPSYCHOLOGIST