Healthcare Provider Details

I. General information

NPI: 1265366587
Provider Name (Legal Business Name): KEGAN C MILLER LLMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 W CENTRE AVE
PORTAGE MI
49024-5309
US

IV. Provider business mailing address

721 W CENTRE AVE
PORTAGE MI
49024-5309
US

V. Phone/Fax

Practice location:
  • Phone: 269-548-7206
  • Fax:
Mailing address:
  • Phone: 269-548-7206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851122256
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: