Provider Demographics
NPI:1306114608
Name:MILLER, KATHLEEN (LMT, LMP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:LMT, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17030 SE 1ST ST STE 102
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-8514
Mailing Address - Country:US
Mailing Address - Phone:360-604-1226
Mailing Address - Fax:
Practice Address - Street 1:17030 SE 1ST ST STE 102
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-8514
Practice Address - Country:US
Practice Address - Phone:360-604-1226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020850225700000X
OR11933225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist