Provider Demographics
NPI:1053306159
Name:MILES, MARK A (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:MILES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 N LAUDERDALE ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-2794
Mailing Address - Country:US
Mailing Address - Phone:901-495-3006
Mailing Address - Fax:901-495-3842
Practice Address - Street 1:332 N LAUDERDALE ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-2794
Practice Address - Country:US
Practice Address - Phone:901-495-3006
Practice Address - Fax:901-495-3842
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2302103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5440556Medicaid
TN5440556Medicaid