Provider Demographics
NPI:1306088414
Name:MILES, MARY MARGARET (MA)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:MARGARET
Last Name:MILES
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12248 SE MOUNTAIN SUN DR
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-6214
Mailing Address - Country:US
Mailing Address - Phone:503-698-3537
Mailing Address - Fax:
Practice Address - Street 1:880 82ND DR
Practice Address - Street 2:GLADSTONE
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027-1803
Practice Address - Country:US
Practice Address - Phone:503-659-5515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000WDBCHOtherGROUP MEDICARE
OR164936Medicaid