Provider Demographics
NPI:1053931816
Name:MILES, DOMENICK
Entity type:Individual
Prefix:
First Name:DOMENICK
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 1:5 QUASAR CT
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-2224
Mailing Address - Country:US
Mailing Address - Phone:215-853-7421
Mailing Address - Fax:
Practice Address - Street 1:551 W LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:HAVERFORD
Practice Address - State:PA
Practice Address - Zip Code:19041-1419
Practice Address - Country:US
Practice Address - Phone:215-853-7421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-22
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor