Healthcare Provider Details

I. General information

NPI: 1639516875
Provider Name (Legal Business Name): DENNIS MANCHESTER-MILES JR. LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2013
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 APEX DR STE 300A
MARLBOROUGH MA
01752-1977
US

IV. Provider business mailing address

11 APEX DR STE 300A
MARLBOROUGH MA
01752-1977
US

V. Phone/Fax

Practice location:
  • Phone: 617-249-3577
  • Fax: 617-812-1702
Mailing address:
  • Phone: 617-249-3577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number126082
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: