Provider Demographics
NPI:1821113770
Name:RAVEN, KRISTA (MS, MFT)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:RAVEN
Suffix:
Gender:F
Credentials:MS, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 E PACIFIC COAST HWY
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-3275
Mailing Address - Country:US
Mailing Address - Phone:310-707-3811
Mailing Address - Fax:310-707-3811
Practice Address - Street 1:4500 E PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-3275
Practice Address - Country:US
Practice Address - Phone:310-707-3811
Practice Address - Fax:310-707-3811
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC49705106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist