Provider Demographics
NPI:1801921499
Name:MILES, TIM
Entity type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:MILES
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:PO BOX 343
Mailing Address - Street 2:
Mailing Address - City:BLUEWATER
Mailing Address - State:NM
Mailing Address - Zip Code:87005-0343
Mailing Address - Country:US
Mailing Address - Phone:505-287-4159
Mailing Address - Fax:
Practice Address - Street 1:402 N SECOND STREET
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020
Practice Address - Country:US
Practice Address - Phone:505-285-2614
Practice Address - Fax:505-287-8487
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM287256103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM32408714Medicaid