Provider Demographics
NPI:1518788280
Name:MILLER, MARK AMBROSE
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:AMBROSE
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 INDUSTRIAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:MAXWELTON
Mailing Address - State:WV
Mailing Address - Zip Code:24957-8066
Mailing Address - Country:US
Mailing Address - Phone:304-497-0500
Mailing Address - Fax:
Practice Address - Street 1:804 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:MAXWELTON
Practice Address - State:WV
Practice Address - Zip Code:24957-8066
Practice Address - Country:US
Practice Address - Phone:304-497-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-24
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
VA0733009089101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health