Provider Demographics
NPI:1215519848
Name:MILES, BRUCE ELLIS SR (LPC)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:ELLIS
Last Name:MILES
Suffix:SR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 CLERK ST
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:LA
Mailing Address - Zip Code:71055-2415
Mailing Address - Country:US
Mailing Address - Phone:318-207-7265
Mailing Address - Fax:
Practice Address - Street 1:1255 SHREVEPORT BARKSDALE HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2405
Practice Address - Country:US
Practice Address - Phone:318-861-1776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5552101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health