Provider Demographics
NPI:1205317930
Name:RAVEON1947
Entity type:Organization
Organization Name:RAVEON1947
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:KAUS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMHC
Authorized Official - Phone:941-685-0265
Mailing Address - Street 1:9040 TOWN CENTER PKWY
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34202-4101
Mailing Address - Country:US
Mailing Address - Phone:941-685-0265
Mailing Address - Fax:
Practice Address - Street 1:9040 TOWN CENTER PARKWAY
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34202-3420
Practice Address - Country:US
Practice Address - Phone:941-685-0265
Practice Address - Fax:941-552-5650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)