Provider Demographics
NPI:1184451866
Name:WILEY, KEVIN G (RLMHCI)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:G
Last Name:WILEY
Suffix:
Gender:M
Credentials:RLMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 CAMELIA ST
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-2500
Mailing Address - Country:US
Mailing Address - Phone:904-635-1966
Mailing Address - Fax:
Practice Address - Street 1:920 CAMELIA ST
Practice Address - Street 2:
Practice Address - City:ATLANTIC BEACH
Practice Address - State:FL
Practice Address - Zip Code:32233-2500
Practice Address - Country:US
Practice Address - Phone:904-635-1966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26578101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty