Provider Demographics
NPI:1295208635
Name:RAVEN, REIZY (COTA)
Entity Type:Individual
Prefix:
First Name:REIZY
Middle Name:
Last Name:RAVEN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 S MAIN ST APT 37
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-5249
Mailing Address - Country:US
Mailing Address - Phone:845-263-6799
Mailing Address - Fax:
Practice Address - Street 1:10 LINK DR
Practice Address - Street 2:
Practice Address - City:ROCKLEIGH
Practice Address - State:NJ
Practice Address - Zip Code:07647-2504
Practice Address - Country:US
Practice Address - Phone:201-784-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09122200224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant