Provider Demographics
NPI:1124651419
Name:MILES, GINA RENEE (LICSW)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:RENEE
Last Name:MILES
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:RENEE
Other - Last Name:FLEMING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:221 W WYNOOCHE AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:MONTESANO
Mailing Address - State:WA
Mailing Address - Zip Code:98563-4401
Mailing Address - Country:US
Mailing Address - Phone:360-797-5241
Mailing Address - Fax:360-249-8495
Practice Address - Street 1:221 W WYNOOCHE AVE UNIT B
Practice Address - Street 2:
Practice Address - City:MONTESANO
Practice Address - State:WA
Practice Address - Zip Code:98563-4401
Practice Address - Country:US
Practice Address - Phone:360-797-5241
Practice Address - Fax:360-249-8495
Is Sole Proprietor?:No
Enumeration Date:2020-02-15
Last Update Date:2020-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA606931741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical