Provider Demographics
NPI:1174850648
Name:MILLER, KENNETH EDMUND JR
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:EDMUND
Last Name:MILLER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 N FAIRLAND ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-4225
Mailing Address - Country:US
Mailing Address - Phone:918-825-2884
Mailing Address - Fax:918-825-2234
Practice Address - Street 1:109 N FAIRLAND ST
Practice Address - Street 2:SUITE 101
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-4203
Practice Address - Country:US
Practice Address - Phone:918-825-2884
Practice Address - Fax:918-825-2234
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker