Healthcare Provider Details

I. General information

NPI: 1144361544
Provider Name (Legal Business Name): MILES DILLER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 11/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

489 MAIN ST
PRINCE FREDERICK MD
20678-3187
US

IV. Provider business mailing address

PO BOX 2924
LA PLATA MD
20646-2984
US

V. Phone/Fax

Practice location:
  • Phone: 410-535-3947
  • Fax: 301-609-9091
Mailing address:
  • Phone: 301-609-9887
  • Fax: 301-609-9091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number723
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number267420
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number02457
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: