Provider Demographics
NPI:1407120959
Name:RAVEN, RESA EILEEN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RESA
Middle Name:EILEEN
Last Name:RAVEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 HARRISON AVE NW STE 2
Mailing Address - Street 2:PMB 511
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-2607
Mailing Address - Country:US
Mailing Address - Phone:360-866-8981
Mailing Address - Fax:
Practice Address - Street 1:2118 CATON WAY SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-1105
Practice Address - Country:US
Practice Address - Phone:360-866-8981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY 60115237103TA0700X, 103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic