Provider Demographics
NPI:1619554581
Name:GIBBS, RAVEN
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:GIBBS
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 1:3623 LAKESHORE DR SW
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-3038
Mailing Address - Country:US
Mailing Address - Phone:678-215-5529
Mailing Address - Fax:
Practice Address - Street 1:3623 LAKESHORE DR SW
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-3038
Practice Address - Country:US
Practice Address - Phone:678-215-5529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA056401493OtherDRIVERS LICENSE