Provider Demographics
NPI:1699875708
Name:MILES, REVAN FISHER
Entity type:Individual
Prefix:MS
First Name:REVAN
Middle Name:FISHER
Last Name:MILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 HARTFORD ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON HIGHLANDS
Mailing Address - State:MA
Mailing Address - Zip Code:02461-1540
Mailing Address - Country:US
Mailing Address - Phone:617-969-3490
Mailing Address - Fax:
Practice Address - Street 1:1180 BEACON ST
Practice Address - Street 2:SUITE 7D
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-3885
Practice Address - Country:US
Practice Address - Phone:671-734-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1014641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical