Provider Demographics
NPI:1750726576
Name:MILLER, BROOKE TAMARA (LSCSW)
Entity type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:TAMARA
Last Name:MILLER
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 N DEERFIELD CT
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:KS
Mailing Address - Zip Code:67002-7986
Mailing Address - Country:US
Mailing Address - Phone:316-650-1877
Mailing Address - Fax:
Practice Address - Street 1:6611 E CENTRAL AVE STE C
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-1937
Practice Address - Country:US
Practice Address - Phone:316-650-1877
Practice Address - Fax:316-358-7713
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-07
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS8520104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201069800 BMedicaid
KS201069800BMedicaid