Provider Demographics
NPI:1396553715
Name:MILES, KEIASYA BREONA
Entity type:Individual
Prefix:
First Name:KEIASYA
Middle Name:BREONA
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 1:3100 FIVE FORKS TRICKUM RD SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-1890
Mailing Address - Country:US
Mailing Address - Phone:470-485-2220
Mailing Address - Fax:855-803-6288
Practice Address - Street 1:3100 FIVE FORKS TRICKUM RD SW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-1890
Practice Address - Country:US
Practice Address - Phone:470-485-2220
Practice Address - Fax:855-803-6288
Is Sole Proprietor?:No
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-23-295862106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician