Provider Demographics
NPI:1750260014
Name:MILLER, KELSIE RYAN
Entity type:Individual
Prefix:
First Name:KELSIE
Middle Name:RYAN
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3362 E FLAMINGO CT
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-8205
Mailing Address - Country:US
Mailing Address - Phone:970-689-7819
Mailing Address - Fax:
Practice Address - Street 1:2509 S POWER RD STE 110
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-6696
Practice Address - Country:US
Practice Address - Phone:480-912-7206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-30
Last Update Date:2025-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-23614101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health