Provider Demographics
NPI:1780379297
Name:RAVENELL, KYLA
Entity type:Individual
Prefix:
First Name:KYLA
Middle Name:
Last Name:RAVENELL
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 1:822 STONEBRIDGE PARK CIR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-9049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3111 GWIN OAKS DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-5112
Practice Address - Country:US
Practice Address - Phone:404-914-5378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GABACB886034106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician