Provider Demographics
NPI:1356497192
Name:MILES, MARMADUKE SIDNEY (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARMADUKE
Middle Name:SIDNEY
Last Name:MILES
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 E 38TH ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31401-8560
Mailing Address - Country:US
Mailing Address - Phone:912-233-1312
Mailing Address - Fax:912-447-5661
Practice Address - Street 1:23 E 38TH ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31401-8560
Practice Address - Country:US
Practice Address - Phone:912-233-1312
Practice Address - Fax:912-447-5661
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0026581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000847591BMedicaid