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General NPI Number Information
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NPI Number | 1518178771
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Entity Type | Individual
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Provider Name | JACQUELINE RUSSIANO MILES PHD
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Gender | Female
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Dates
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Enumeration Date | 05/26/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 745 S MARENGO AVE SUITE 203
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City | PASADENA
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State | CA
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Zip | 91106-4735
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Country | US
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Telephone | 626-577-4733
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Fax |
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Provider Business Mailing Address
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Address Line | 3568 MOUNTAIN VIEW AVE
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City | PASADENA
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State | CA
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Zip | 91107-4616
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Country | US
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Telephone | 626-440-9974
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Fax | 626-440-9979
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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 | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 7882
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License Number State | CA
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