MEDICARE: MATTHEW TELLIFERALD MILES LCSW-A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	P013435	NC

General Provider Information

NPI Number	:	1104488402
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW TELLIFERALD MILES LCSW-A

Provider Business Mailing Address
First Line	:	15081 HIGHWAY 130 E
Second Line	:
City	:	FAIRMONT
State	:	NC
Zip	:	28340-5553
Country	:	US
Telephone Number	:	910-374-8118
Fax Number	:

Provider Business Practice Location Address
First Line	:	2409 N ELM ST
Second Line	:
City	:	LUMBERTON
State	:	NC
Zip	:	28358-3658
Country	:	US
Telephone Number	:	910-802-4365
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2019
Last Update Date	:	07/08/2019

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