Healthcare Provider Details

I. General information

NPI: 1083310163
Provider Name (Legal Business Name): TA'TIANA NICOLE MILES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2023
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13800 FARNSWORTH LN
UPPER MARLBORO MD
20772-5802
US

IV. Provider business mailing address

13800 FARNSWORTH LN APT 5204
UPPER MARLBORO MD
20772-5803
US

V. Phone/Fax

Practice location:
  • Phone: 202-455-8437
  • Fax:
Mailing address:
  • Phone: 202-455-8437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number29586
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLG50083841
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC200003113
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: