Provider Demographics
NPI:1225641657
Name:CERVANTES, RAQUEL (BCBA)
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:CERVANTES
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4468 CARROLLTON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-1916
Mailing Address - Country:US
Mailing Address - Phone:219-730-4515
Mailing Address - Fax:
Practice Address - Street 1:1353 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-1433
Practice Address - Country:US
Practice Address - Phone:317-520-4748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-20-42844103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst