Healthcare Provider Details

I. General information

NPI: 1760066500
Provider Name (Legal Business Name): KENDRA MARIE MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2021
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 LONG BEACH BLVD STE 700
LONG BEACH CA
90807-2000
US

IV. Provider business mailing address

9486 S MILITARY TRL UNIT 5
BOYNTON BEACH FL
33436-2923
US

V. Phone/Fax

Practice location:
  • Phone: 818-894-2273
  • Fax: 818-357-2505
Mailing address:
  • Phone: 301-697-7832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number37051
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number9633
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number9633
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSL017746
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202010391
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: