Provider Demographics
NPI:1134540362
Name:ROYAL, RAVEN
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:ROYAL
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:RAVEN
Other - Middle Name:
Other - Last Name:ROYAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:7404 DELTAWIND DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-5201
Mailing Address - Country:US
Mailing Address - Phone:916-218-2226
Mailing Address - Fax:
Practice Address - Street 1:129 E CENTER ST STE 3
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4648
Practice Address - Country:US
Practice Address - Phone:209-239-5553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-13
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109H00000X106H00000X
CA109237106H00000X
171M00000X
CA134483106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator