Provider Demographics
NPI:1881196384
Name:MILES, REBECCA MARY (LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARY
Last Name:MILES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1128 DRIFTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-2791
Mailing Address - Country:US
Mailing Address - Phone:314-303-4224
Mailing Address - Fax:
Practice Address - Street 1:216 W SANDBANK, SUITE 14
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-6223
Practice Address - Country:US
Practice Address - Phone:618-370-0960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-01
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0216481041C0700X
MO20180003141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical