=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093468761
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTINE ANN MILLER MSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2022
-----------------------------------------------------
Last Update Date | 02/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2851 UNIVERSITY AVE
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54311-5855
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-431-2500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3093 SAINT GREGORY DR
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54311-5950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-634-1176
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 128328-12
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 128328-121
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------