Provider Demographics
NPI:1760356158
Name:MILLER, KIMBERLY JEANNE (LADC SUPERVISOR)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JEANNE
Last Name:MILLER
Suffix:
Gender:F
Credentials:LADC SUPERVISOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5108 W 74TH ST STE 776
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-2464
Mailing Address - Country:US
Mailing Address - Phone:612-208-8202
Mailing Address - Fax:
Practice Address - Street 1:1624 HARMON PL STE 203
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-1902
Practice Address - Country:US
Practice Address - Phone:510-208-8202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-30
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306301101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty