Provider Demographics
NPI:1992365340
Name:KING-SMITH, RAVEN JANEEN
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:JANEEN
Last Name:KING-SMITH
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 1:6109 AMBLESIDE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129
Mailing Address - Country:US
Mailing Address - Phone:318-518-3553
Mailing Address - Fax:
Practice Address - Street 1:6109 AMBLESIDE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-7112
Practice Address - Country:US
Practice Address - Phone:318-518-3553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator