Basic Information
Provider Information | |||||||||
NPI: | 1184789430 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILLER | ||||||||
FirstName: | DANIEL | ||||||||
MiddleName: | LLOYD | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA LMFT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1900 SILVER LAKE RD NW STE 110 | ||||||||
Address2: |   | ||||||||
City: | NEW BRIGHTON | ||||||||
State: | MN | ||||||||
PostalCode: | 551121789 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6516289566 | ||||||||
FaxNumber: | 6516280411 | ||||||||
Practice Location | |||||||||
Address1: | 207 JEFFERSON BLVD | ||||||||
Address2: |   | ||||||||
City: | BIG LAKE | ||||||||
State: | MN | ||||||||
PostalCode: | 55309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7633676080 | ||||||||
FaxNumber: | 7632637897 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/27/2006 | ||||||||
LastUpdateDate: | 07/27/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 987 | MN | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 62-26715 | 01 | MN | MEDICA ID NUMBER | OTHER | 104M9MI | 01 | MN | BCBS ID NUMBER | OTHER | HP41030 | 01 | MN | HEALTH PARTNERS ID NUMBER | OTHER | 974688900 | 05 | MN |   | MEDICAID |