Provider Demographics
NPI:1093166639
Name:MILLER, KATHLEEN (LSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:
Other - Last Name:MILLER-DAKOTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LSW
Mailing Address - Street 1:10100 ELIDA RD
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45833-9056
Mailing Address - Country:US
Mailing Address - Phone:330-305-1668
Mailing Address - Fax:330-305-1696
Practice Address - Street 1:10100 ELIDA RD
Practice Address - Street 2:
Practice Address - City:DELPHOS
Practice Address - State:OH
Practice Address - Zip Code:45833-9056
Practice Address - Country:US
Practice Address - Phone:419-659-8010
Practice Address - Fax:419-659-0565
Is Sole Proprietor?:No
Enumeration Date:2016-06-24
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0025070101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2847496Medicaid