1497952949 NPI number — MONTE C MILLER PSYD

Table of content: (NPI 1497952949)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497952949 NPI number — MONTE C MILLER PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MONTE C MILLER PSYD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497952949
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24165 IH-10 W
Provider Second Line Business Mailing Address:
STE 217-475
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78257-1159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-892-2333
Provider Business Mailing Address Fax Number:
855-532-9272

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24165 IH-10 W
Provider Second Line Business Practice Location Address:
STE 217-475
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78257-1159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-892-2333
Provider Business Practice Location Address Fax Number:
855-532-9272
Provider Enumeration Date:
06/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
MONTE
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
210-219-6151

Provider Taxonomy Codes

  • Taxonomy code: 103TA0700X , with the licence number:  25472 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 079562701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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