Provider Demographics
NPI:1558305565
Name:MILLER, KATHRYN BREVARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:BREVARD
Last Name:MILLER
Suffix:
Gender:F
Credentials:PHD
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Mailing Address - Street 1:5101 OLSON MEMORIAL HWY
Mailing Address - Street 2:SUITE 4004
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-5149
Mailing Address - Country:US
Mailing Address - Phone:763-595-7294
Mailing Address - Fax:763-595-7293
Practice Address - Street 1:5101 OLSON MEMORIAL HWY
Practice Address - Street 2:SUITE 4004
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-5149
Practice Address - Country:US
Practice Address - Phone:763-595-7294
Practice Address - Fax:763-595-7293
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2008-05-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN4359103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN365LOMIOtherBLUECROSSBLUESHIELD
MN128427400Medicaid
MN128427400Medicaid