Provider Demographics
NPI:1134631211
Name:WILES, BREANA (LCSW)
Entity type:Individual
Prefix:
First Name:BREANA
Middle Name:
Last Name:WILES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1342 LAKESHORE AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-1656
Mailing Address - Country:US
Mailing Address - Phone:818-970-1093
Mailing Address - Fax:
Practice Address - Street 1:1080 MARINA VILLAGE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-1078
Practice Address - Country:US
Practice Address - Phone:510-217-2329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-30
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAACSW89169101YM0800X
390200000X
CA1084321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program