Provider Demographics
NPI:1659734598
Name:MILES, KATHRYN VICTORIA
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:VICTORIA
Last Name:MILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:MILES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4383 KANSAS ST APT 8
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-1249
Mailing Address - Country:US
Mailing Address - Phone:915-613-8241
Mailing Address - Fax:
Practice Address - Street 1:4383 KANSAS ST APT 8
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-1249
Practice Address - Country:US
Practice Address - Phone:915-613-8241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA117884101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program