Provider Demographics
NPI:1477675460
Name:RAVEN, DENISE M (LISW)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:M
Last Name:RAVEN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2917 CARLISLE BLVD NE STE 105
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-2489
Mailing Address - Country:US
Mailing Address - Phone:505-269-0212
Mailing Address - Fax:505-312-8684
Practice Address - Street 1:2917 CARLISLE BLVD NE STE 105
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-2489
Practice Address - Country:US
Practice Address - Phone:505-269-0212
Practice Address - Fax:505-312-8684
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-049261041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM81006853Medicaid