Provider Demographics
NPI:1629665401
Name:NILES, VENISE
Entity Type:Individual
Prefix:
First Name:VENISE
Middle Name:
Last Name:NILES
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 1:251 ROBIN ST UNIT 9
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-3003
Mailing Address - Country:US
Mailing Address - Phone:678-334-0433
Mailing Address - Fax:
Practice Address - Street 1:251 ROBIN ST UNIT 9
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3003
Practice Address - Country:US
Practice Address - Phone:678-334-0433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician