Basic Information
Provider Information
NPI: 1003018151
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MILLER
FirstName: BRUCE
MiddleName: VICTOR
NamePrefix: DR.
NameSuffix:  
Credential: PHD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 125 COULTER AVE
Address2:  
City: ARDMORE
State: PA
PostalCode: 19003
CountryCode: US
TelephoneNumber: 6106424873
FaxNumber: 6106424886
Practice Location
Address1: 125 COULTER AVE
Address2:  
City: ARDMORE
State: PA
PostalCode: 19003
CountryCode: US
TelephoneNumber: 6106424873
FaxNumber: 6106424886
Other Information
ProviderEnumerationDate: 06/01/2007
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
103TC0700XPS00231LPAY Behavioral Health & Social Service ProvidersPsychologistClinical

No ID Information.


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