Provider Demographics
NPI:1952506305
Name:MILES, SALLY (PHD, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:MILES
Suffix:
Gender:F
Credentials:PHD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-5875
Mailing Address - Country:US
Mailing Address - Phone:608-241-1442
Mailing Address - Fax:
Practice Address - Street 1:521 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-5875
Practice Address - Country:US
Practice Address - Phone:608-241-1442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2929-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42585700Medicaid