Provider Demographics
NPI:1336202316
Name:MILLIKEN, KIRSTEN W (PHD)
Entity Type:Individual
Prefix:DR
First Name:KIRSTEN
Middle Name:W
Last Name:MILLIKEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10437
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104
Mailing Address - Country:US
Mailing Address - Phone:207-772-4191
Mailing Address - Fax:207-899-2840
Practice Address - Street 1:837 BROADWAY
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2708
Practice Address - Country:US
Practice Address - Phone:207-772-4191
Practice Address - Fax:888-688-1460
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS924103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME13550000Medicaid
MEMM7070Medicare ID - Type Unspecified