Provider Demographics
NPI:1992462287
Name:MILLER, BREANNA MICHELLE (RN, LCSW)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:MICHELLE
Last Name:MILLER
Suffix:
Gender:F
Credentials:RN, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4620 SOVEREIGN BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-6421
Mailing Address - Country:US
Mailing Address - Phone:815-222-8884
Mailing Address - Fax:
Practice Address - Street 1:415 S MULFORD RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-3011
Practice Address - Country:US
Practice Address - Phone:815-399-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-21
Last Update Date:2021-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.023843104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker