Provider Demographics
NPI:1083014799
Name:MILLER, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
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 1:685 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45786-0272
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:920 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW LEXINGTON
Practice Address - State:OH
Practice Address - Zip Code:43764-1552
Practice Address - Country:US
Practice Address - Phone:740-342-5161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH08805225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant