Healthcare Provider Details

I. General information

NPI: 1609428697
Provider Name (Legal Business Name): KELVIN LEWIS MILLER PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CENTURY DR
WORCESTER MA
01606-1244
US

IV. Provider business mailing address

10 LUPINE RD
NATICK MA
01760-2004
US

V. Phone/Fax

Practice location:
  • Phone: 844-319-0000
  • Fax:
Mailing address:
  • Phone: 832-766-6347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License NumberRN2348591
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberAP141951
License Number StateTX

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: