Healthcare Provider Details

I. General information

NPI: 1952038069
Provider Name (Legal Business Name): RAVEN BROOKE ATES ALC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3263 DEMETROPOLIS RD STE 1
MOBILE AL
36693-4638
US

IV. Provider business mailing address

3263 DEMETROPOLIS RD STE 1
MOBILE AL
36693-4638
US

V. Phone/Fax

Practice location:
  • Phone: 251-280-8086
  • Fax: 251-281-8086
Mailing address:
  • Phone: 251-281-8086
  • Fax: 251-281-8086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC4145A
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: