Healthcare Provider Details

I. General information

NPI: 1912255449
Provider Name (Legal Business Name): VINCENT MILES PSY.D. LP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2012
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 25TH AVE S SUITE 105
SAINT CLOUD MN
56301-4800
US

IV. Provider business mailing address

606 25TH AVE S SUITE 105
SAINT CLOUD MN
56301-4800
US

V. Phone/Fax

Practice location:
  • Phone: 320-247-4737
  • Fax: 320-365-0080
Mailing address:
  • Phone: 320-247-4737
  • Fax: 320-365-0080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberLP5676
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP5676
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP5676
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: