Provider Demographics
NPI:1326190158
Name:MILES, MARGO (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARGO
Middle Name:
Last Name:MILES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-3905
Mailing Address - Country:US
Mailing Address - Phone:801-328-9204
Mailing Address - Fax:801-582-1392
Practice Address - Street 1:150 S 600 E STE 10D
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1961
Practice Address - Country:US
Practice Address - Phone:801-328-9204
Practice Address - Fax:801-582-1392
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT369759-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical