Provider Demographics
NPI:1023521838
Name:MAYES, RAEVEN CHANAE
Entity type:Individual
Prefix:
First Name:RAEVEN
Middle Name:CHANAE
Last Name:MAYES
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 1:1907 BOYS REPUBLIC DR
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-5447
Mailing Address - Country:US
Mailing Address - Phone:909-628-1217
Mailing Address - Fax:909-993-1106
Practice Address - Street 1:184 N IVY AVE
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-2220
Practice Address - Country:US
Practice Address - Phone:626-357-0957
Practice Address - Fax:909-306-5427
Is Sole Proprietor?:No
Enumeration Date:2017-11-15
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96829101YM0800X, 1041C0700X
CA1181841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health