Provider Demographics
NPI:1548421928
Name:NITZ, MILES (LMFT)
Entity Type:Individual
Prefix:
First Name:MILES
Middle Name:
Last Name:NITZ
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10515 ILLINOIS RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46814-9182
Practice Address - Country:US
Practice Address - Phone:260-373-9200
Practice Address - Fax:260-373-9219
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-19
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001567A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000572676OtherANTHEM
IN351972384007OtherTRICARE