Provider Demographics
NPI:1669247102
Name:RAVEN, MARINA (PDMT, LMT)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:RAVEN
Suffix:
Gender:F
Credentials:PDMT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9920 E SOUTHPORT RD REAR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46259-1420
Mailing Address - Country:US
Mailing Address - Phone:317-513-7725
Mailing Address - Fax:
Practice Address - Street 1:8202 CLEARVISTA PKWY STE 9F
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1457
Practice Address - Country:US
Practice Address - Phone:317-204-4285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT20901841225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist