Provider Demographics
NPI:1114644135
Name:BEASLEY, RAVEN (TLLP)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14111 GREENVIEW RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-2911
Mailing Address - Country:US
Mailing Address - Phone:734-957-6304
Mailing Address - Fax:
Practice Address - Street 1:705 S MAIN ST STE 280
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1060
Practice Address - Country:US
Practice Address - Phone:734-454-3560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-20
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist