Provider Demographics
NPI:1699114207
Name:MILLER, KELLEY NOELLE
Entity type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:NOELLE
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 1:4676 RIVERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-3764
Mailing Address - Country:US
Mailing Address - Phone:248-762-7389
Mailing Address - Fax:
Practice Address - Street 1:4676 RIVERVIEW DR
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-3764
Practice Address - Country:US
Practice Address - Phone:248-762-7389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL2437424101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401013280OtherLLPC