Basic Information
| Provider Information | |||||||||
| NPI: | 1407107683 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | KRISTY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | SWT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHEW | ||||||||
| OtherFirstName: | KRISTY | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2546 KENILWORTH RD APT 23 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441062475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122010245 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 22001 FAIRMOUNT BLVD | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441184819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2169322800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2012 | ||||||||
| LastUpdateDate: | 09/27/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041S0200X | S.1200192-TRNE | OH | Y | Behavioral Health & Social Service Providers | Social Worker | School |
No ID Information.