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General NPI Number Information
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NPI Number | 1083906499
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Entity Type | Individual
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Provider Name | JEROME RICHARD MYLES MA
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Gender | Male
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Dates
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Enumeration Date | 05/04/2011
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Last Update Date | 06/13/2011
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Provider Practice Location Address
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Address Line | 8522 RICHARDSON KING RD
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City | WAXHAW
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State | NC
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Zip | 28173-8738
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Country | US
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Telephone | 704-614-2823
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 402
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City | WAXHAW
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State | NC
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Zip | 28173-1046
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Country | US
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Telephone | 704-614-2823
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | A7806
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License Number State | NC
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