Provider Demographics
NPI:1912255449
Name:MILES, VINCENT (PSYD LP)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:
Last Name:MILES
Suffix:
Gender:M
Credentials:PSYD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 25TH AVE S
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4800
Mailing Address - Country:US
Mailing Address - Phone:320-247-4737
Mailing Address - Fax:320-365-0080
Practice Address - Street 1:606 25TH AVE S
Practice Address - Street 2:SUITE 105
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4800
Practice Address - Country:US
Practice Address - Phone:320-247-4737
Practice Address - Fax:320-365-0080
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-15
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5676103TH0004X, 103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103T00000XBehavioral Health & Social Service ProvidersPsychologist