Provider Demographics
NPI:1144941022
Name:MILLER, KEVIN (MA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2614 N CLYBOURN AVE APT 207
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1060
Mailing Address - Country:US
Mailing Address - Phone:815-931-0560
Mailing Address - Fax:
Practice Address - Street 1:636 CHURCH ST STE 321
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4579
Practice Address - Country:US
Practice Address - Phone:815-931-0560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty