Provider Demographics
NPI:1265163687
Name:MILLER, KENDRA MARIE SUDDETH (LISW-CP)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:MARIE SUDDETH
Last Name:MILLER
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 72
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-0072
Mailing Address - Country:US
Mailing Address - Phone:803-587-8327
Mailing Address - Fax:
Practice Address - Street 1:412 SADDLECREST CT
Practice Address - Street 2:
Practice Address - City:BLYTHEWOOD
Practice Address - State:SC
Practice Address - Zip Code:29016-7631
Practice Address - Country:US
Practice Address - Phone:803-587-8327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041S0200X
SC135811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool