Provider Demographics
NPI:1275127631
Name:MOSS, RAVEN
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:MOSS
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 1:45-112 LILIPUNA RD
Mailing Address - Street 2:
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-3020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:45-480 KANEOHE BAY DR
Practice Address - Street 2:
Practice Address - City:KANEOHE
Practice Address - State:HI
Practice Address - Zip Code:96744-2039
Practice Address - Country:US
Practice Address - Phone:808-524-3689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-16509225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist