Provider Demographics
NPI:1104973890
Name:MILLER-URBAN, KIMBERLEE LYNNE (MA EDS)
Entity type:Individual
Prefix:MS
First Name:KIMBERLEE
Middle Name:LYNNE
Last Name:MILLER-URBAN
Suffix:
Gender:F
Credentials:MA EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N GADWALL CT
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-7159
Mailing Address - Country:US
Mailing Address - Phone:910-538-5334
Mailing Address - Fax:
Practice Address - Street 1:2002 EASTWOOD RD
Practice Address - Street 2:SUITE 305
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-7218
Practice Address - Country:US
Practice Address - Phone:910-509-0588
Practice Address - Fax:910-509-0586
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2612103T00000X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1063488773Medicare UPIN