MEDICARE: RAVEON1947

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1205317930
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RAVEON1947

Provider Business Mailing Address
First Line	:	9040 TOWN CENTER PKWY
Second Line	:
City	:	LAKEWOOD RANCH
State	:	FL
Zip	:	34202-4101
Country	:	US
Telephone Number	:	941-685-0265
Fax Number	:

Provider Business Practice Location Address
First Line	:	9040 TOWN CENTER PARKWAY
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34202-3420
Country	:	US
Telephone Number	:	941-685-0265
Fax Number	:	941-552-5650

Authorized Official
Title or Position	:	OWNER
Name	:	MR. DAVID L KAUS
Credential	:	MA, LMHC
Telephone Number	:	941-685-0265

Provider Enumeration Date	:	08/21/2018
Last Update Date	:	08/21/2018

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