Provider Demographics
NPI:1609662063
Name:MILES, MICHAEL D JR
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:MILES
Suffix:JR
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 PARK PLAZA DR # 1219
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-2647
Mailing Address - Country:US
Mailing Address - Phone:614-603-3246
Mailing Address - Fax:
Practice Address - Street 1:1582 N WAGGONER RD STE A
Practice Address - Street 2:
Practice Address - City:BLACKLICK
Practice Address - State:OH
Practice Address - Zip Code:43004-8669
Practice Address - Country:US
Practice Address - Phone:614-344-0419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-15
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician