Provider Demographics
NPI:1679105845
Name:MILLER, KRYSTLE D (LPCC)
Entity type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:D
Last Name:MILLER
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:KRYSTLE
Other - Middle Name:DAWN
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPCC
Mailing Address - Street 1:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-858-6655
Mailing Address - Fax:270-858-4027
Practice Address - Street 1:158 COL CASEY DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:KY
Practice Address - Zip Code:42728-5319
Practice Address - Country:US
Practice Address - Phone:844-435-0900
Practice Address - Fax:270-858-4029
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-06
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY288498101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY16074862OtherCAQH
KY7100941590Medicaid