Provider Demographics
NPI:1255948477
Name:TAYLOR, RAVEN S (MD)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:S
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1124 HATCHIE ST
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38012-3427
Mailing Address - Country:US
Mailing Address - Phone:731-432-1327
Mailing Address - Fax:
Practice Address - Street 1:1124 HATCHIE ST
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38012-3427
Practice Address - Country:US
Practice Address - Phone:731-432-1327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN119946379103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst