Provider Demographics
NPI:1114969409
Name:KATHRYN B. MILLER, P.A.
Entity Type:Organization
Organization Name:KATHRYN B. MILLER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:BREVARD
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:763-595-7294
Mailing Address - Street 1:5101 OLSON MEMORIAL HWY
Mailing Address - Street 2:SUITE 4004
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-5149
Mailing Address - Country:US
Mailing Address - Phone:763-595-7294
Mailing Address - Fax:763-595-7293
Practice Address - Street 1:5101 OLSON MEMORIAL HWY
Practice Address - Street 2:SUITE 4004
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-5149
Practice Address - Country:US
Practice Address - Phone:763-595-7294
Practice Address - Fax:763-595-7293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4359103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN023640000Medicaid
MN365L0MIOtherBLUECROSS BLUESHIELD OF MN
MN023640000Medicaid