Provider Demographics
NPI:1881396364
Name:ALLEN, RAVEN
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:ALLEN
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 1:3020 LAMBERTON BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-9124
Mailing Address - Country:US
Mailing Address - Phone:407-534-0033
Mailing Address - Fax:689-348-4395
Practice Address - Street 1:3020 LAMBERTON BLVD STE 107
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-9124
Practice Address - Country:US
Practice Address - Phone:407-534-0033
Practice Address - Fax:689-348-4395
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-263052106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician