Provider Demographics
NPI:1023652286
Name:MILES, ALYSSA NICOLE (MA SLP-CCC)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:NICOLE
Last Name:MILES
Suffix:
Gender:F
Credentials:MA SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 SWALLOW DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63144-1619
Mailing Address - Country:US
Mailing Address - Phone:618-420-4129
Mailing Address - Fax:
Practice Address - Street 1:650 OFFICE PKWY
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7103
Practice Address - Country:US
Practice Address - Phone:314-838-1465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018030275235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2018030275OtherSPEECH LANGUAGE PATHOLOGIST