Provider Demographics
NPI:1891815882
Name:MILES, MICHAEL L
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:L
Last Name:MILES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 LEE AVE
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3623
Mailing Address - Country:US
Mailing Address - Phone:631-289-0696
Mailing Address - Fax:
Practice Address - Street 1:755 WAVERLY AVE STE 216
Practice Address - Street 2:
Practice Address - City:HOLTSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11742-1125
Practice Address - Country:US
Practice Address - Phone:631-654-3519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-31
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9802760011041S0200X
NY0433851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool