Provider Demographics
NPI:1922693712
Name:GADDIS, RAVEN (DPT)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:GADDIS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9907
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73153-5307
Mailing Address - Country:US
Mailing Address - Phone:405-455-7860
Mailing Address - Fax:405-455-7865
Practice Address - Street 1:8809 S SOONER RD STE E
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73135-6605
Practice Address - Country:US
Practice Address - Phone:405-455-7860
Practice Address - Fax:405-455-7865
Is Sole Proprietor?:No
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5788225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist