Provider Demographics
NPI:1255440285
Name:MILLER, KATHLEEN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 SOUTH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-1737
Mailing Address - Country:US
Mailing Address - Phone:207-222-1012
Mailing Address - Fax:
Practice Address - Street 1:75 SOUTH ST STE 2
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:ME
Practice Address - Zip Code:04038-1737
Practice Address - Country:US
Practice Address - Phone:207-222-1012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP1651235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME018316OtherANTHEM BLUE CROSS AND BLU
ME431938399Medicaid