Provider Demographics
NPI:1346902988
Name:KING, RAVEN (BS,MC)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:BS,MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 MISSION AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92058-7110
Mailing Address - Country:US
Mailing Address - Phone:760-712-3535
Mailing Address - Fax:760-439-6901
Practice Address - Street 1:1701 MISSION AVE STE 230
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-7110
Practice Address - Country:US
Practice Address - Phone:760-712-3535
Practice Address - Fax:760-439-6901
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-11
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 101Y00000X
CA14013101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor