Provider Demographics
NPI:1346393824
Name:MILES, MAURICE RANDOLPH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MAURICE
Middle Name:RANDOLPH
Last Name:MILES
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:DR
Other - First Name:M.
Other - Middle Name:RANDY
Other - Last Name:MILES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:9 ELMWOOD CT
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-1401
Mailing Address - Country:US
Mailing Address - Phone:860-953-1204
Mailing Address - Fax:860-953-1208
Practice Address - Street 1:9 ELMWOOD CT
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-1401
Practice Address - Country:US
Practice Address - Phone:860-953-1204
Practice Address - Fax:860-953-1208
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT538101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional