Provider Demographics
NPI:1912427667
Name:MILLER, KANISHA FORDHAM
Entity Type:Individual
Prefix:
First Name:KANISHA
Middle Name:FORDHAM
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 MIDDLEFIELD CT
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29680-7054
Mailing Address - Country:US
Mailing Address - Phone:843-709-3392
Mailing Address - Fax:
Practice Address - Street 1:24 MIDDLEFIELD CT
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29680-7054
Practice Address - Country:US
Practice Address - Phone:843-709-3392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6383101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional