Healthcare Provider Details

I. General information

NPI: 1427836246
Provider Name (Legal Business Name): TYERRA MILES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2023
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7310 WOODWARD AVE STE 601
DETROIT MI
48202-3165
US

IV. Provider business mailing address

13725 BIRCH TREE WAY
SHELBY TOWNSHIP MI
48315-6001
US

V. Phone/Fax

Practice location:
  • Phone: 313-896-4444
  • Fax:
Mailing address:
  • Phone: 313-669-5017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number6362010008
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: