Provider Demographics
NPI:1780235416
Name:MANCHESTER-MILES, MICHAEL (LICSW, LADC-I)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MANCHESTER-MILES
Suffix:
Gender:M
Credentials:LICSW, LADC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 APEX DR STE 300A
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-1977
Mailing Address - Country:US
Mailing Address - Phone:617-249-3577
Mailing Address - Fax:617-812-1702
Practice Address - Street 1:11 APEX DR STE 300A
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-1977
Practice Address - Country:US
Practice Address - Phone:617-249-3577
Practice Address - Fax:617-812-1702
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15623101YA0400X, 101YA0400X
MALICSW11215721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical