Provider Demographics
NPI:1568280055
Name:MILES, JEWLIE
Entity type:Individual
Prefix:
First Name:JEWLIE
Middle Name:
Last Name:MILES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3485 N HOLIDAY DR
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34428-7905
Mailing Address - Country:US
Mailing Address - Phone:352-364-7210
Mailing Address - Fax:
Practice Address - Street 1:8001 BEATY GROVE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-1602
Practice Address - Country:US
Practice Address - Phone:813-926-5454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-02
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLRBT24391843106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician