Provider Demographics
NPI:1700197571
Name:MILLER, KIM DIAN (MS, CCC/A)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:DIAN
Last Name:MILLER
Suffix:
Gender:F
Credentials:MS, CCC/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 12TH AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3929
Mailing Address - Country:US
Mailing Address - Phone:817-335-8151
Mailing Address - Fax:
Practice Address - Street 1:1001 12TH AVE STE 150
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3929
Practice Address - Country:US
Practice Address - Phone:817-335-8151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50761231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist