Provider Demographics
NPI:1649077074
Name:ILES, KELCIE
Entity type:Individual
Prefix:
First Name:KELCIE
Middle Name:
Last Name:ILES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 CARTER ST
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37402-5017
Mailing Address - Country:US
Mailing Address - Phone:318-237-0766
Mailing Address - Fax:
Practice Address - Street 1:1101 CARTER ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37402-5017
Practice Address - Country:US
Practice Address - Phone:318-237-0766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-25
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1776103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst