Provider Demographics
NPI:1730120478
Name:MILLER, KENNETH SCOTT (LMSW)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:SCOTT
Last Name:MILLER
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 W LAKE LANSING RD STE 100
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-8452
Mailing Address - Country:US
Mailing Address - Phone:517-798-6118
Mailing Address - Fax:
Practice Address - Street 1:780 W LAKE LANSING RD STE 100
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8452
Practice Address - Country:US
Practice Address - Phone:517-798-6118
Practice Address - Fax:517-955-9191
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33002131A104100000X
IN34003388A1041C0700X
MI68010847091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC36108020Medicare ID - Type Unspecified