Provider Demographics
NPI:1770113078
Name:MILES, JOANNA R (EDD)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:R
Last Name:MILES
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 LOSITO LN
Mailing Address - Street 2:
Mailing Address - City:AGAWAM
Mailing Address - State:MA
Mailing Address - Zip Code:01001-3607
Mailing Address - Country:US
Mailing Address - Phone:413-348-0056
Mailing Address - Fax:
Practice Address - Street 1:155 MAPLE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-2649
Practice Address - Country:US
Practice Address - Phone:413-285-8722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-25
Last Update Date:2020-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA939103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool