Provider Demographics
NPI:1568021137
Name:MILLER, KIM (CADC)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 S SUMMER HILL RD
Mailing Address - Street 2:
Mailing Address - City:POLO
Mailing Address - State:IL
Mailing Address - Zip Code:61064-9101
Mailing Address - Country:US
Mailing Address - Phone:815-973-0450
Mailing Address - Fax:
Practice Address - Street 1:748 TIMBER CREEK RD
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-9564
Practice Address - Country:US
Practice Address - Phone:815-284-3940
Practice Address - Fax:815-284-9267
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL25047101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)