Provider Demographics
NPI:1386238343
Name:MILLER, ETHAN PATRICK
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:PATRICK
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 1:5982 RHODES RD
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-8100
Mailing Address - Country:US
Mailing Address - Phone:330-673-1347
Mailing Address - Fax:330-678-3677
Practice Address - Street 1:960 GRAHAM RD STE 3
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44221-1155
Practice Address - Country:US
Practice Address - Phone:330-606-9262
Practice Address - Fax:234-678-4858
Is Sole Proprietor?:No
Enumeration Date:2021-02-21
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHC.2304866101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator