Provider Demographics
NPI:1710642939
Name:MILES, RAVEN MARIE KILLINGER
Entity Type:Individual
Prefix:MRS
First Name:RAVEN
Middle Name:MARIE KILLINGER
Last Name:MILES
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:RAVEN
Other - Middle Name:MARIE
Other - Last Name:KILLINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 8268
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96830-0268
Mailing Address - Country:US
Mailing Address - Phone:475-227-6396
Mailing Address - Fax:
Practice Address - Street 1:94-657 NAKILI PL
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-4142
Practice Address - Country:US
Practice Address - Phone:475-227-6396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-02
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-21-195464106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician