Provider Demographics
NPI:1609336148
Name:MILES, HEIDI LYNN (THW)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:LYNN
Last Name:MILES
Suffix:
Gender:F
Credentials:THW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7110 SW FIR LOOP STE 160
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8031
Mailing Address - Country:US
Mailing Address - Phone:503-507-9417
Mailing Address - Fax:
Practice Address - Street 1:7110 SW FIR LOOP STE 160
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8031
Practice Address - Country:US
Practice Address - Phone:503-507-9417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000002928175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR000002928Medicaid