Provider Demographics
NPI:1669185708
Name:GARZA, RAVEN
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:GARZA
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 1:1605 COUNTY LINE RD APT E102
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80504-8562
Mailing Address - Country:US
Mailing Address - Phone:806-773-1319
Mailing Address - Fax:
Practice Address - Street 1:1605 COUNTY LINE RD APT E102
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80504-8562
Practice Address - Country:US
Practice Address - Phone:806-773-1319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMFTC.0014388106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist