Basic Information
| Provider Information | |||||||||
| NPI: | 1255598264 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | MANDY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25828 REDLANDS BLVD | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923738449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098257084 | ||||||||
| FaxNumber: | 9513584719 | ||||||||
| Practice Location | |||||||||
| Address1: | 769 W BLAINE ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925073970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513584705 | ||||||||
| FaxNumber: | 9513584719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2008 | ||||||||
| LastUpdateDate: | 10/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCS 27136 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.