Provider Demographics
NPI:1114525508
Name:WRIGHT, RAVEN ELEXIS (COTA/L, CNA, CMT)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:ELEXIS
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:COTA/L, CNA, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 FOXWORTH ST
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-6322
Mailing Address - Country:US
Mailing Address - Phone:803-972-0032
Mailing Address - Fax:
Practice Address - Street 1:157 HOME AVE
Practice Address - Street 2:
Practice Address - City:DARLINGTON
Practice Address - State:SC
Practice Address - Zip Code:29532-7625
Practice Address - Country:US
Practice Address - Phone:843-393-2867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC560347376K00000X
SC5175224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No376K00000XNursing Service Related ProvidersNurse's Aide