Provider Demographics
NPI:1609650134
Name:WILSON, RAVEN (MED, LPC-A)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MED, LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10511 SAGEBERRY DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77089-2901
Mailing Address - Country:US
Mailing Address - Phone:832-348-7159
Mailing Address - Fax:
Practice Address - Street 1:1560 W BAY AREA BLVD STE 303
Practice Address - Street 2:
Practice Address - City:FRIENDSWOOD
Practice Address - State:TX
Practice Address - Zip Code:77546-2681
Practice Address - Country:US
Practice Address - Phone:832-657-1489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX91896101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health