Provider Demographics
NPI:1720628100
Name:ROGERS, RAVEN (BCBA)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 ENGLISH OAKS DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-5794
Mailing Address - Country:US
Mailing Address - Phone:904-874-9349
Mailing Address - Fax:
Practice Address - Street 1:2121 NEW MARKET PKWY SE STE 122
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-9309
Practice Address - Country:US
Practice Address - Phone:770-667-3877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11939491103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst