Provider Demographics
NPI:1609375617
Name:VEGA, RAVEN (APC, NCC)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:VEGA
Suffix:
Gender:F
Credentials:APC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 SHALLOWFORD RD NE APT 4323
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-1225
Mailing Address - Country:US
Mailing Address - Phone:732-379-1825
Mailing Address - Fax:
Practice Address - Street 1:1708 PEACHTREE ST NW STE 425
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-7020
Practice Address - Country:US
Practice Address - Phone:404-565-4385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-05
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
GAAPC008017101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician