Provider Demographics
NPI:1134683295
Name:SMALL, RAVEN
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:SMALL
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 1:2104 GREENBRIAR DR STE A
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-8355
Mailing Address - Country:US
Mailing Address - Phone:817-442-9022
Mailing Address - Fax:
Practice Address - Street 1:4722 RIVERSTONE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-4723
Practice Address - Country:US
Practice Address - Phone:346-368-4412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-18-56410OtherBACB