Provider Demographics
NPI:1053692848
Name:MILLER, PHYLLIS WARDRETT (MSW,LCSW)
Entity type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:WARDRETT
Last Name:MILLER
Suffix:
Gender:F
Credentials:MSW,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-3328
Mailing Address - Country:US
Mailing Address - Phone:404-626-9690
Mailing Address - Fax:404-377-5644
Practice Address - Street 1:204 CHURCH ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3328
Practice Address - Country:US
Practice Address - Phone:404-626-9690
Practice Address - Fax:404-377-5644
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-07
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW000649104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA132600OtherCENPATICO
GA003112377AMedicaid
753207OtherWELLCARE
3561762OtherCIGNA INSURANCE
GA1902141617OtherBLUE CROSS/BLUE SHIELD OF GEORGIA