Healthcare Provider Details

I. General information

NPI: 1548637507
Provider Name (Legal Business Name): MILES PSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2015
Last Update Date: 08/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 25TH AVE S SUITE 105
SAINT CLOUD MN
56301-4810
US

IV. Provider business mailing address

606 25TH AVE S SUITE 105
SAINT CLOUD MN
56301-4810
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 TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberLP5676
License Number StateMN

VIII. Authorized Official

Name: DR. VINCENT MILES
Title or Position: LICENSED PSYCHOLOGIST
Credential: PSYD LP
Phone: 13202474737