Provider Demographics
NPI:1407920283
Name:MILLER, KEVIN WAYNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:WAYNE
Last Name:MILLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 S WEBSTER AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2288
Mailing Address - Country:US
Mailing Address - Phone:920-366-7792
Mailing Address - Fax:
Practice Address - Street 1:2131 S WEBSTER AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2288
Practice Address - Country:US
Practice Address - Phone:920-366-7792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2309-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI84011Medicare ID - Type UnspecifiedMEDICARE ID