Provider Demographics
NPI:1336263987
Name:MILLER, MAX A (MA, LCMHC)
Entity type:Individual
Prefix:MR
First Name:MAX
Middle Name:A
Last Name:MILLER
Suffix:
Gender:M
Credentials:MA, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 VICTORIA DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-6627
Mailing Address - Country:US
Mailing Address - Phone:802-860-1588
Mailing Address - Fax:802-658-2234
Practice Address - Street 1:34 PATCHEN RD
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-5704
Practice Address - Country:US
Practice Address - Phone:802-658-4208
Practice Address - Fax:802-658-2234
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0680000523101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1007669Medicaid