Basic Information
| Provider Information | |||||||||
| NPI: | 1972629160 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 227 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FESTUS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630281952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369312700 | ||||||||
| FaxNumber: | 6369315304 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 MUNICIPAL DR | ||||||||
| Address2: | |||||||||
| City: | ARNOLD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630101012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362966206 | ||||||||
| FaxNumber: | 6362960102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 07/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | 2008014112 | MO | N | Other Service Providers | Case Manager/Care Coordinator | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.