Provider Demographics
NPI:1700137114
Name:MILES, VICTORIA (PHD,HHP)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:MILES
Suffix:
Gender:F
Credentials:PHD,HHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 BICYCLE PATH
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:538 BICYCLE PATH
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-3410
Practice Address - Country:US
Practice Address - Phone:631-721-6935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
66673205103TB0200X, 103TC1900X, 103TH0100X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist