Provider Demographics
NPI:1730387523
Name:WILES, ANDREA BAYLEN (OTRL AND BCBA)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:BAYLEN
Last Name:WILES
Suffix:
Gender:F
Credentials:OTRL AND BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 LEGACY DR
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-9594
Mailing Address - Country:US
Mailing Address - Phone:859-358-2791
Mailing Address - Fax:
Practice Address - Street 1:910 RED HOUSE RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-9326
Practice Address - Country:US
Practice Address - Phone:859-353-5505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R2863225X00000X
KY276099103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist