Basic Information
| Provider Information | |||||||||
| NPI: | 1508584400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MYLES | ||||||||
| FirstName: | KIYANAH | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | APCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6185 MAGNOLIA AVE # 338 | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925062524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512502888 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 658 E BRIER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924082847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095010700 | ||||||||
| FaxNumber: | 9093877611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2022 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | 12371 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.