Provider Demographics
NPI:1689834186
Name:MILES, ROBERT EDWIN (PHD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:EDWIN
Last Name:MILES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 732973
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-2973
Mailing Address - Country:US
Mailing Address - Phone:817-702-2450
Mailing Address - Fax:817-702-8445
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-702-3636
Practice Address - Fax:817-927-8769
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33304103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX88877AOtherBCBS
TXP00736154OtherRAILROAD MEDICARE
TX197008901Medicaid
TX197008901Medicaid