Healthcare Provider Details

I. General information

NPI: 1326320920
Provider Name (Legal Business Name): MATTHEW R MILETTE-WINFREE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 475
FPO AP
96350-9998
US

IV. Provider business mailing address

PSC 475 BOX 1678
FPO AP
96350-1678
US

V. Phone/Fax

Practice location:
  • Phone: 315-243-5485
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY-1841
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY-1841
License Number StateHI
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-1841
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: