Basic Information
| Provider Information | |||||||||
| NPI: | 1730387523 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILES | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | BAYLEN | ||||||||
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| Credential: | OTRL AND BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 129 LEGACY DR | ||||||||
| Address2: | |||||||||
| City: | BEREA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404039594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593582791 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 RICHMOND RD N | ||||||||
| Address2: | |||||||||
| City: | BEREA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404038788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8599864710 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2007 | ||||||||
| LastUpdateDate: | 03/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 276099 | KY | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 225X00000X | KY-R2863 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.