Healthcare Provider Details

I. General information

NPI: 1265838593
Provider Name (Legal Business Name): KAITLYN D MILLER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2014
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4103 BOARDWALK DR UNIT 202
FORT COLLINS CO
80525-5930
US

IV. Provider business mailing address

125 CRESTRIDGE ST
FORT COLLINS CO
80525-3934
US

V. Phone/Fax

Practice location:
  • Phone: 970-494-9870
  • Fax:
Mailing address:
  • Phone: 970-494-9761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number09927628
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: