Healthcare Provider Details

I. General information

NPI: 1356177299
Provider Name (Legal Business Name): MILES XAVIER CONKLIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16110 JAMAICA AVE STE 306
JAMAICA NY
11432-6149
US

IV. Provider business mailing address

10124 134TH ST
SOUTH RICHMOND HILL NY
11419-2307
US

V. Phone/Fax

Practice location:
  • Phone: 718-674-1000
  • Fax:
Mailing address:
  • Phone: 917-370-6312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: