Provider Demographics
NPI:1215089636
Name:MILLER, RICHARD A
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 N DUTTON AVE
Mailing Address - Street 2:STE C
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4687
Mailing Address - Country:US
Mailing Address - Phone:707-303-1532
Mailing Address - Fax:707-571-1895
Practice Address - Street 1:1360 N DUTTON AVE
Practice Address - Street 2:STE C
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4687
Practice Address - Country:US
Practice Address - Phone:707-303-1532
Practice Address - Fax:707-571-1895
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA146205Medicare UPIN