Provider Demographics
NPI:1073152336
Name:MILLER, KIMBERLY SUE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 PLEASANT GROVE CH RD
Mailing Address - Street 2:
Mailing Address - City:MARSHVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28103-9052
Mailing Address - Country:US
Mailing Address - Phone:704-733-7108
Mailing Address - Fax:
Practice Address - Street 1:10801 MONROE RD
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-8335
Practice Address - Country:US
Practice Address - Phone:704-733-7108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-03
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCPO14249104100000X
NCP0142491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCPO14249OtherLCSWA