Provider Demographics
NPI:1386340545
Name:MILLER, CHARLES (PSYD, LCP)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:PSYD, LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BROADWAY
Mailing Address - State:VA
Mailing Address - Zip Code:22815-9751
Mailing Address - Country:US
Mailing Address - Phone:703-975-5821
Mailing Address - Fax:
Practice Address - Street 1:250 MEMORIAL DR STE B
Practice Address - Street 2:
Practice Address - City:LURAY
Practice Address - State:VA
Practice Address - Zip Code:22835-1000
Practice Address - Country:US
Practice Address - Phone:540-568-1735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810008068103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical