Provider Demographics
NPI:1720069255
Name:MILLER, G. DICK (PHD10/24/19)
Entity type:Individual
Prefix:DR
First Name:G.
Middle Name:DICK
Last Name:MILLER
Suffix:
Gender:M
Credentials:PHD10/24/19
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 W AIRPORT FWY
Mailing Address - Street 2:SUITE 185
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021
Mailing Address - Country:US
Mailing Address - Phone:817-283-8484
Mailing Address - Fax:817-283-8286
Practice Address - Street 1:4001 W AIRPORT FWY
Practice Address - Street 2:SUITE 185
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021
Practice Address - Country:US
Practice Address - Phone:817-283-8484
Practice Address - Fax:817-283-8286
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-1081103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXJC76OtherBC/BS PROVIDER NUMBER