1114428968 NPI number — ALEXANDRA SUTHERLAND MILES BCBA

Table of content: GABRIEL CLEMENTS PT (NPI 1720084940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114428968 NPI number — ALEXANDRA SUTHERLAND MILES BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILES
Provider First Name:
ALEXANDRA
Provider Middle Name:
SUTHERLAND
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114428968
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 VILLAGE SQ STE 210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21210-1624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-525-4271
Provider Business Mailing Address Fax Number:
443-743-3863

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6325 N CENTER DR STE 121
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23502-0012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-565-7222
Provider Business Practice Location Address Fax Number:
877-734-1914
Provider Enumeration Date:
02/27/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-21-55838 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1114428968 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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