Provider Demographics
NPI:1962170506
Name:MILES, LATASIA
Entity type:Individual
Prefix:
First Name:LATASIA
Middle Name:
Last Name:MILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18968 W MONROE ST
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-5727
Mailing Address - Country:US
Mailing Address - Phone:602-483-3957
Mailing Address - Fax:
Practice Address - Street 1:18968 W MONROE ST
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-5727
Practice Address - Country:US
Practice Address - Phone:602-483-3957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH6936251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health