Provider Demographics
NPI:1689623308
Name:MILLER, KATHRYN A (MS, LPC MHSP)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:A
Last Name:MILLER
Suffix:
Gender:F
Credentials:MS, LPC MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4646 POPLAR AVE STE 424
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-4434
Mailing Address - Country:US
Mailing Address - Phone:901-767-4748
Mailing Address - Fax:901-767-4749
Practice Address - Street 1:4646 POPLAR AVE STE 424
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4434
Practice Address - Country:US
Practice Address - Phone:901-767-4748
Practice Address - Fax:901-767-4749
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN582101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4015818OtherBLUE CROSS BLUE SHIELD ID
TN472238OtherVALUE OPTIONS ID
TN5441094Medicaid