Provider Demographics
NPI:1437568441
Name:MILES, KATIE MICHELLE (CTRS, MS, PCMHT)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MICHELLE
Last Name:MILES
Suffix:
Gender:F
Credentials:CTRS, MS, PCMHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 E RIVER PL
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-3442
Mailing Address - Country:US
Mailing Address - Phone:769-251-5550
Mailing Address - Fax:
Practice Address - Street 1:11 WOODSTONE PLZ STE D
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-8342
Practice Address - Country:US
Practice Address - Phone:769-390-7234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS101Y00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor