Basic Information
| Provider Information | |||||||||
| NPI: | 1356568638 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | LAWRENCE | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 33 MORNINGSIDE RD | ||||||||
| Address2: | |||||||||
| City: | NEEDHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024923920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175761098 | ||||||||
| FaxNumber: | 7814385553 | ||||||||
| Practice Location | |||||||||
| Address1: | 875 MASSACHUSETTS AVE | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021393067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175761098 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 3406 | MA | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | W03598 | 01 | MA | BLUE CROSS BLUE SHIELD ID | OTHER | 102722 | 01 | MH | MAGELLAN | OTHER | 715194 | 01 | MD | TUFTS | OTHER | 8656-01 | 01 | MA | PACIFICARE | OTHER |