MEDICARE: HOLLIE MILES LCSW

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	0710102921	VA
2	1041C0700X	Clinical Social Worker	0904009557	VA

General Provider Information

NPI Number	:	1760936918
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLIE MILES LCSW

Provider Business Mailing Address
First Line	:	PO BOX 72984
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23235-8023
Country	:	US
Telephone Number	:	434-572-7184
Fax Number	:

Provider Business Practice Location Address
First Line	:	1905 HUGUENOT RD STE 303C
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23235
Country	:	US
Telephone Number	:	804-346-6327
Fax Number	:

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

Provider Enumeration Date	:	08/04/2016
Last Update Date	:	11/08/2019

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