Healthcare Provider Details

I. General information

NPI: 1104630771
Provider Name (Legal Business Name): CASSIDY LEIGH MILES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2025
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1290 TAVERN RD
MAMMOTH LAKES CA
93546-6601
US

IV. Provider business mailing address

PO BOX 2619
MAMMOTH LAKES CA
93546-2619
US

V. Phone/Fax

Practice location:
  • Phone: 760-924-1740
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: