=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750260014
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELSIE RYAN MILLER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2025
-----------------------------------------------------
Last Update Date | 08/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2509 S POWER RD STE 110
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85209-6696
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-912-7206
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3362 E FLAMINGO CT
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85297-8205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-689-7819
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LAC-23614
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------