Provider Demographics
NPI:1861361594
Name:ROSA, RAVEN ALEXIS
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:ALEXIS
Last Name:ROSA
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 1:5870 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-2037
Mailing Address - Country:US
Mailing Address - Phone:951-683-6596
Mailing Address - Fax:
Practice Address - Street 1:4295 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3446
Practice Address - Country:US
Practice Address - Phone:951-683-6596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-31
Last Update Date:2025-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42465167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes167G00000XNursing Service ProvidersLicensed Psychiatric TechnicianGroup - Single Specialty