Provider Demographics
NPI:1609316165
Name:OZUNA, RAEVEN HAILEY
Entity Type:Individual
Prefix:
First Name:RAEVEN
Middle Name:HAILEY
Last Name:OZUNA
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 1:7102 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-4105
Mailing Address - Country:US
Mailing Address - Phone:917-795-9369
Mailing Address - Fax:
Practice Address - Street 1:7102 PARK AVE
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-4105
Practice Address - Country:US
Practice Address - Phone:917-795-9369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-03
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator