Provider Demographics
NPI:1861530651
Name:MILLER, BRAD (PSYD)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9666 BUSINESSPARK AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-1646
Mailing Address - Country:US
Mailing Address - Phone:858-549-3031
Mailing Address - Fax:
Practice Address - Street 1:9666 BUSINESSPARK AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-1646
Practice Address - Country:US
Practice Address - Phone:858-549-3031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 17229103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY 172290Medicaid