MEDICARE: KENNY EDWARD MILLER MSW, LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCSW-2095	AZ

General Provider Information

NPI Number	:	1457429367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNY EDWARD MILLER MSW, LCSW

Provider Business Mailing Address
First Line	:	3131 N COUNTRY CLUB RD STE 201
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85716-1651
Country	:	US
Telephone Number	:	520-326-8424
Fax Number	:	520-326-8669

Provider Business Practice Location Address
First Line	:	3131 N COUNTRY CLUB RD STE 201
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85716-1651
Country	:	US
Telephone Number	:	520-326-8424
Fax Number	:	520-326-8669

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2006
Last Update Date	:	07/08/2007

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