Provider Demographics
NPI:1700353976
Name:MILLER, KRISTIN MARIE (LCPC)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:MILLER
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:MARIE
Other - Last Name:GAVIGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LGPC
Mailing Address - Street 1:8967 YELLOW BRICK RD
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-2303
Mailing Address - Country:US
Mailing Address - Phone:410-780-4320
Mailing Address - Fax:410-987-4301
Practice Address - Street 1:1114 BENFIELD BLVD STE G
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-2589
Practice Address - Country:US
Practice Address - Phone:410-780-4320
Practice Address - Fax:410-987-4301
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC7950101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional