Provider Demographics
NPI:1174908305
Name:MILES, MELODY
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:
Last Name:MILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 ANNABELLE CV
Mailing Address - Street 2:
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-2625
Mailing Address - Country:US
Mailing Address - Phone:662-315-6679
Mailing Address - Fax:662-256-8314
Practice Address - Street 1:1111 EARL FRYE BLVD
Practice Address - Street 2:
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821-5516
Practice Address - Country:US
Practice Address - Phone:662-257-4048
Practice Address - Fax:662-257-4080
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
MSOT3129225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No251S00000XAgenciesCommunity/Behavioral Health