Provider Demographics
NPI:1922754118
Name:MILLERE, MAURICELM-LEI I (PSYCHIATRY CLINICIAN)
Entity type:Individual
Prefix:DR
First Name:MAURICELM-LEI
Middle Name:
Last Name:MILLERE
Suffix:I
Gender:M
Credentials:PSYCHIATRY CLINICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 GARLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HELENA
Mailing Address - State:AR
Mailing Address - Zip Code:72390-2440
Mailing Address - Country:US
Mailing Address - Phone:270-801-3436
Mailing Address - Fax:
Practice Address - Street 1:112 GARLAND AVE
Practice Address - Street 2:
Practice Address - City:WEST HELENA
Practice Address - State:AR
Practice Address - Zip Code:72390-2440
Practice Address - Country:US
Practice Address - Phone:270-801-3436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR261QR0405X261QR0405X
NC261QR0405X261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH201823400828OtherSTATE OF OHIO CERTIFICATE / TRADE NAME REGISTRATION