Basic Information
| Provider Information | |||||||||
| NPI: | 1033252796 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | KOTYS | ||||||||
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| Credential: | MS, CCC-SP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601791 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601791 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1730 KERNERSVILLE MEDICAL PKWY STE 201 | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272847198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369967001 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SP6360 | OH | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 11686 | NC | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 2095254 | 05 | OH | MEDICAID |