Provider Demographics
NPI:1003955311
Name:RAVEN, KENNETH (PHD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:RAVEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 W. ROLLING OAKS DR.
Mailing Address - Street 2:SUITE #107
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91361-1003
Mailing Address - Country:US
Mailing Address - Phone:805-497-7001
Mailing Address - Fax:805-498-8076
Practice Address - Street 1:25 W. ROLLING OAKS DR.
Practice Address - Street 2:SUITE #107
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-1003
Practice Address - Country:US
Practice Address - Phone:805-497-7001
Practice Address - Fax:805-498-8076
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY6491103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical