Provider Demographics
NPI:1518008549
Name:MILES, LAURETTA BEATRICE (LCSWC LICENSED CERTI)
Entity type:Individual
Prefix:MS
First Name:LAURETTA
Middle Name:BEATRICE
Last Name:MILES
Suffix:
Gender:F
Credentials:LCSWC LICENSED CERTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 MAIN STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-5592
Mailing Address - Country:US
Mailing Address - Phone:301-520-5920
Mailing Address - Fax:301-977-6026
Practice Address - Street 1:244 MAIN STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-5592
Practice Address - Country:US
Practice Address - Phone:301-520-5920
Practice Address - Fax:301-977-6026
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-11
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD094131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD492080DCMedicare UPIN