Provider Demographics
NPI:1104488402
Name:MILES, MATTHEW TELLIFERALD (LCSW-A)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:TELLIFERALD
Last Name:MILES
Suffix:
Gender:M
Credentials:LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15081 HIGHWAY 130 E
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28340-5553
Mailing Address - Country:US
Mailing Address - Phone:910-374-8118
Mailing Address - Fax:
Practice Address - Street 1:2409 N ELM ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3658
Practice Address - Country:US
Practice Address - Phone:910-802-4365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0134351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical