Provider Demographics
NPI:1518762756
Name:MARY ELLEN MILLER, MS, LPC, LLC
Entity type:Organization
Organization Name:MARY ELLEN MILLER, MS, LPC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY ELLEN
Authorized Official - Middle Name:ELLEN MILLER MS
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:608-617-8419
Mailing Address - Street 1:W10445 STATE ROAD 16 LOT 21
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-9488
Mailing Address - Country:US
Mailing Address - Phone:608-617-8419
Mailing Address - Fax:
Practice Address - Street 1:W10445 STATE ROAD 16 LOT 21
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9488
Practice Address - Country:US
Practice Address - Phone:608-617-8419
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-13
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)