Provider Demographics
NPI:1336471903
Name:MILLER, KELLY B (MHR)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:B
Last Name:MILLER
Suffix:
Gender:M
Credentials:MHR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2732 NW 161ST STREET
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013
Mailing Address - Country:US
Mailing Address - Phone:405-202-2466
Mailing Address - Fax:
Practice Address - Street 1:2732 NW 161ST ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-1218
Practice Address - Country:US
Practice Address - Phone:405-202-2466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-08
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)