Provider Demographics
NPI:1700917820
Name:RAEVEN, AGNES (ACSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:AGNES
Middle Name:
Last Name:RAEVEN
Suffix:
Gender:F
Credentials:ACSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 THEATRE CTR
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-2410
Mailing Address - Country:US
Mailing Address - Phone:973-729-3722
Mailing Address - Fax:570-296-2043
Practice Address - Street 1:3 THEATRE CTR
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-2410
Practice Address - Country:US
Practice Address - Phone:973-729-3722
Practice Address - Fax:570-296-2043
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJSCO8663103TA0400X, 103TA0700X, 103TC2200X, 103TF0000X, 103T00000X, 103TP2701X, 103TR0400X, 104100000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist