Provider Demographics
NPI:1497249015
Name:LEWIS, RAVEN (RSW)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:RSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 BUSINESS PARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70427
Mailing Address - Country:US
Mailing Address - Phone:888-417-5250
Mailing Address - Fax:
Practice Address - Street 1:106 BUSINESS PARK AVENUE
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70427
Practice Address - Country:US
Practice Address - Phone:888-417-5250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13889104100000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA00000000Medicaid