Provider Demographics
NPI:1689409252
Name:WILEY-HUNT, RAVEN CIARA
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:CIARA
Last Name:WILEY-HUNT
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 1:6548 HUNTINGTON CT
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-3040
Mailing Address - Country:US
Mailing Address - Phone:678-557-3678
Mailing Address - Fax:
Practice Address - Street 1:6548 HUNTINGTON CT
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-3040
Practice Address - Country:US
Practice Address - Phone:678-557-3678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056397175106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician