Provider Demographics
NPI:1609069921
Name:RAVEN, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:RAVEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10951 SE STEVENS WAY
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-7435
Mailing Address - Country:US
Mailing Address - Phone:503-206-9696
Mailing Address - Fax:
Practice Address - Street 1:2505 SE 11TH AVE STE 332
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1063
Practice Address - Country:US
Practice Address - Phone:503-206-9696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3475101YP2500X
OR10-12-70101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional