Provider Demographics
NPI:1326473430
Name:MILLER, KISHA LASHONE
Entity Type:Individual
Prefix:MS
First Name:KISHA
Middle Name:LASHONE
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KISHA
Other - Middle Name:LASHONE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:11105 212TH ST
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-1811
Mailing Address - Country:US
Mailing Address - Phone:917-449-2674
Mailing Address - Fax:
Practice Address - Street 1:1149 47TH AVE
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-5418
Practice Address - Country:US
Practice Address - Phone:646-306-4443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-09
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY72088854104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker