Basic Information
| Provider Information | |||||||||
| NPI: | 1093327124 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | LCAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 MESEROLE AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112222404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9174083180 | ||||||||
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| Practice Location | |||||||||
| Address1: | 705 MANHATTAN AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112222909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3474748464 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2020 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 221700000X | 002718 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Art Therapist |
No ID Information.