Healthcare Provider Details

I. General information

NPI: 1447612031
Provider Name (Legal Business Name): MARY KATHRYNE MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 03/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 TURNERSBURG HWY
STATESVILLE NC
28625-2798
US

IV. Provider business mailing address

318 TURNERSBURG HWY
STATESVILLE NC
28625-2798
US

V. Phone/Fax

Practice location:
  • Phone: 704-873-1114
  • Fax: 704-873-9917
Mailing address:
  • Phone: 704-873-1114
  • Fax: 704-873-9917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: