Basic Information
| Provider Information | |||||||||
| NPI: | 1194063610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILES | ||||||||
| FirstName: | ALISA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | INTERN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2109 S HIGHWAY 69 | ||||||||
| Address2: | |||||||||
| City: | WAGONER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744679310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187083006 | ||||||||
| FaxNumber: | 9189990109 | ||||||||
| Practice Location | |||||||||
| Address1: | 11740 E 21ST ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741291820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184379495 | ||||||||
| FaxNumber: | 9185601399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2013 | ||||||||
| LastUpdateDate: | 03/12/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 1194063610 | 05 | OK | MEDICAID |