Basic Information
| Provider Information | |||||||||
| NPI: | 1972161412 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILES | ||||||||
| FirstName: | HEATHER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PIONEER WAY | ||||||||
| Address2: | |||||||||
| City: | MAGEE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391115501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018496440 | ||||||||
| FaxNumber: | 6018491332 | ||||||||
| Practice Location | |||||||||
| Address1: | 1151 HIGHWAY 35 S | ||||||||
| Address2: | |||||||||
| City: | FOREST | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390748829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014692732 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2019 | ||||||||
| LastUpdateDate: | 05/30/2019 | ||||||||
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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 | 225X00000X | OT2361 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | OT2361 | 01 | MS | LICENSE | OTHER |