Provider Demographics
NPI:1649938614
Name:MILLER, KENNETH LOGAN (RBT)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:LOGAN
Last Name:MILLER
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N RICHARD JACKSON BLVD
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-3664
Mailing Address - Country:US
Mailing Address - Phone:850-866-0441
Mailing Address - Fax:850-254-0827
Practice Address - Street 1:810 SHONEY DR SW STE 115
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-5450
Practice Address - Country:US
Practice Address - Phone:256-692-9262
Practice Address - Fax:888-392-7185
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALRBT-21-195626106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician