Provider Demographics
NPI:1508272998
Name:HARDIN, RAVEN
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:HARDIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10401 BROCKINGTON RD
Mailing Address - Street 2:APT #416
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-4306
Mailing Address - Country:US
Mailing Address - Phone:501-247-1379
Mailing Address - Fax:
Practice Address - Street 1:10401 BROCKINGTON RD
Practice Address - Street 2:APT #416
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72120-4306
Practice Address - Country:US
Practice Address - Phone:501-247-1379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health