Provider Demographics
NPI:1275621468
Name:MILES, GARY TERRELL (PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:TERRELL
Last Name:MILES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:80 GREAT OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95119-1310
Mailing Address - Country:US
Mailing Address - Phone:408-363-3037
Mailing Address - Fax:408-363-3046
Practice Address - Street 1:80 GREAT OAKS BLVD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119-1310
Practice Address - Country:US
Practice Address - Phone:408-363-3037
Practice Address - Fax:408-363-3046
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12101103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist