Provider Demographics
NPI:1588974836
Name:MILLER, JUSTIN MICHAEL (LCSW)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:MILLER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11279 PERRY HWY STE 450
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-9303
Mailing Address - Country:US
Mailing Address - Phone:724-933-1100
Mailing Address - Fax:
Practice Address - Street 1:20630 ROUTE 19 UNIT 101
Practice Address - Street 2:
Practice Address - City:CRANBERRY TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:16066-6021
Practice Address - Country:US
Practice Address - Phone:724-779-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0200361041C0700X
WVBP00943159104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005456001Medicaid