Provider Demographics
NPI:1013593342
Name:MILES, THEODORE PHILIP (CADAC II)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:PHILIP
Last Name:MILES
Suffix:
Gender:M
Credentials:CADAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 W BLOOMFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2051
Mailing Address - Country:US
Mailing Address - Phone:812-558-0574
Mailing Address - Fax:
Practice Address - Street 1:1355 W BLOOMFIELD RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2051
Practice Address - Country:US
Practice Address - Phone:812-558-0574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INC2-1990101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)