Basic Information
| Provider Information | |||||||||
| NPI: | 1700197571 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | DIAN | ||||||||
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| Credential: | M.S., CCC/A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 12TH AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173358151 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1001 12TH AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173358151 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2010 | ||||||||
| LastUpdateDate: | 06/28/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 50761 | TX | Y | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.