Basic Information
| Provider Information | |||||||||
| NPI: | 1174843767 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4900 BROADWAY | ||||||||
| Address2: | SUITE 2800 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958201532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167349313 | ||||||||
| FaxNumber: | 9167349661 | ||||||||
| Practice Location | |||||||||
| Address1: | 4860 Y ST | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958172307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167343588 | ||||||||
| FaxNumber: | 9167349661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2010 | ||||||||
| LastUpdateDate: | 05/01/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 23018 | CA | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC0700X | 23018 | CA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.