Provider Demographics
NPI:1356177299
Name:CONKLIN, MILES XAVIER
Entity type:Individual
Prefix:
First Name:MILES
Middle Name:XAVIER
Last Name:CONKLIN
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 1:10124 134TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11419-2307
Mailing Address - Country:US
Mailing Address - Phone:917-370-6312
Mailing Address - Fax:
Practice Address - Street 1:16110 JAMAICA AVE STE 306
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-6149
Practice Address - Country:US
Practice Address - Phone:718-674-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health