Provider Demographics
NPI:1033478904
Name:LILES, RAY EVERETT (DSW, LCSW)
Entity Type:Individual
Prefix:DR
First Name:RAY
Middle Name:EVERETT
Last Name:LILES
Suffix:
Gender:M
Credentials:DSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1029
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:CA
Mailing Address - Zip Code:92325-1029
Mailing Address - Country:US
Mailing Address - Phone:909-645-8579
Mailing Address - Fax:
Practice Address - Street 1:1255 E HIGHLAND AVE STE 107
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4652
Practice Address - Country:US
Practice Address - Phone:909-645-8579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-11
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS75321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical