Healthcare Provider Details

I. General information

NPI: 1144786658
Provider Name (Legal Business Name): KIMBERLY MILLER LCSW, SAC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2019
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 ANNEX RD
JEFFERSON WI
53549-9803
US

IV. Provider business mailing address

N114 WEST ST APT 6
WATERLOO WI
53594-9214
US

V. Phone/Fax

Practice location:
  • Phone: 920-674-3105
  • Fax:
Mailing address:
  • Phone: 920-904-0770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number18467-130
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number131240-121
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9598-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: