MEDICARE: RAIVEN CLARKE

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1588537542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAIVEN CLARKE

Provider Business Mailing Address
First Line	:	1207 E 107TH ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90002-3560
Country	:	US
Telephone Number	:	323-921-2749
Fax Number	:

Provider Business Practice Location Address
First Line	:	1207 E 107TH ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90002-3560
Country	:	US
Telephone Number	:	323-921-2749
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2025
Last Update Date	:	09/25/2025

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Directions to “ RAIVEN CLARKE ” Practice Location

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