Provider Demographics
NPI:1356818579
Name:MILES, AMETHYST
Entity Type:Individual
Prefix:
First Name:AMETHYST
Middle Name:
Last Name:MILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 HUDSON LN
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5705
Mailing Address - Country:US
Mailing Address - Phone:318-381-8584
Mailing Address - Fax:877-819-9001
Practice Address - Street 1:2017 HUDSON LN
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5705
Practice Address - Country:US
Practice Address - Phone:318-381-8584
Practice Address - Fax:877-819-9001
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator