Healthcare Provider Details

I. General information

NPI: 1871356378
Provider Name (Legal Business Name): KENDRA MILLER LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2024
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E BROADWAY AVE
BISMARCK ND
58501-3840
US

IV. Provider business mailing address

101 E BROADWAY AVE
BISMARCK ND
58501-3840
US

V. Phone/Fax

Practice location:
  • Phone: 701-222-0386
  • Fax:
Mailing address:
  • Phone: 701-222-0386
  • Fax: 701-291-8456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6532
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1963
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: