Provider Demographics
NPI:1831734227
Name:WARD, RAVEN ALANNAH
Entity type:Individual
Prefix:MS
First Name:RAVEN
Middle Name:ALANNAH
Last Name:WARD
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 1:45111 FERN AVE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-2301
Mailing Address - Country:US
Mailing Address - Phone:661-949-1206
Mailing Address - Fax:661-940-5452
Practice Address - Street 1:45111 FERN AVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2301
Practice Address - Country:US
Practice Address - Phone:661-949-1206
Practice Address - Fax:661-940-5452
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-09
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X, 390200000X
CA16222101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765OtherMEDI-CAL