Provider Demographics
NPI:1487889390
Name:MILES, TRACIE ADELE (MA LPC)
Entity type:Individual
Prefix:MS
First Name:TRACIE
Middle Name:ADELE
Last Name:MILES
Suffix:
Gender:F
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 E. 5TH ST.
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090
Mailing Address - Country:US
Mailing Address - Phone:314-303-3602
Mailing Address - Fax:636-293-1117
Practice Address - Street 1:426 E. 5TH ST.
Practice Address - Street 2:3RD FLOOR
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090
Practice Address - Country:US
Practice Address - Phone:314-303-3602
Practice Address - Fax:636-293-1117
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-20
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008035457101YP2500X
MO2008036457101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional