Individual
KIMBERLY MILLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LCSW, SAC-IT
Contact information
Practice address
1541 ANNEX RD, JEFFERSON, WI 53549-9803
(920) 674-3105
Mailing address
N114 WEST ST APT 6, WATERLOO, WI 53594-9214
(920) 904-0770
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
18467-130
WI
104100000X
Social Worker
131240-121
WI
1041C0700X
Clinical Social Worker
Primary
9598-123
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
42138100
—
WI
Enumeration date
02/20/2019
Last updated
01/26/2021
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