Provider Demographics
NPI:1194892976
Name:MILLER, MARY SOISSON (MSW, LISW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SOISSON
Last Name:MILLER
Suffix:
Gender:F
Credentials:MSW, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 NORTH MAIN STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-7520
Mailing Address - Country:US
Mailing Address - Phone:937-748-8201
Mailing Address - Fax:937-748-8206
Practice Address - Street 1:550 NORTH MAIN STREET
Practice Address - Street 2:SUITE B
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-7520
Practice Address - Country:US
Practice Address - Phone:937-748-8201
Practice Address - Fax:937-748-8206
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-00085291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MISW23622Medicare UPIN