Provider Demographics
NPI:1720589088
Name:PRESCOTT MILES, LANDYN T R
Entity Type:Individual
Prefix:
First Name:LANDYN
Middle Name:T R
Last Name:PRESCOTT 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 1:903 N PINE ST
Mailing Address - Street 2:
Mailing Address - City:ROYALTON
Mailing Address - State:MN
Mailing Address - Zip Code:56373-9169
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20547 US HWY 71 SOUTH
Practice Address - Street 2:
Practice Address - City:LONG PRIARIE
Practice Address - State:MN
Practice Address - Zip Code:56347
Practice Address - Country:US
Practice Address - Phone:218-790-3409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01414101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty