Provider Demographics
NPI:1952717092
Name:RAVEN'S SONG REHABILITATION, LLC
Entity Type:Organization
Organization Name:RAVEN'S SONG REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:FERGUSON-WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:907-315-7949
Mailing Address - Street 1:6811 W SCATTERS WAY
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99623-0878
Mailing Address - Country:US
Mailing Address - Phone:907-315-7949
Mailing Address - Fax:877-220-7510
Practice Address - Street 1:6811 W SCATTERS WAY
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99623-0878
Practice Address - Country:US
Practice Address - Phone:907-315-7949
Practice Address - Fax:877-220-7510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1004364261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy