Provider Demographics
NPI:1205590767
Name:ROSE, RAVEN NALIKA (LMFT)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:NALIKA
Last Name:ROSE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:773 CENTER BLVD UNIT 581
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:CA
Mailing Address - Zip Code:94978-5710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3200 E GUASTI RD
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-8660
Practice Address - Country:US
Practice Address - Phone:909-295-5805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-29
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA126047106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist