Provider Demographics
NPI:1164957858
Name:MILLER, KELSEY
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:BAUER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3395 PLYMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-3765
Mailing Address - Country:US
Mailing Address - Phone:952-939-0396
Mailing Address - Fax:952-548-8760
Practice Address - Street 1:3251 FERNBROOK LN N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5352
Practice Address - Country:US
Practice Address - Phone:612-268-5858
Practice Address - Fax:952-548-8760
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01511101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health