Provider Demographics
NPI:1306297049
Name:MILLER, KELLY RITA (BS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RITA
Last Name:MILLER
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2267 CABANA CLUB COURT #204
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612
Mailing Address - Country:US
Mailing Address - Phone:239-677-9863
Mailing Address - Fax:
Practice Address - Street 1:2267 CABANA CLUB COURT #204
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612
Practice Address - Country:US
Practice Address - Phone:239-677-9863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst