Healthcare Provider Details

I. General information

NPI: 1386551935
Provider Name (Legal Business Name): RAVEN V TAYLOR-ADUWAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 E PALM LN STE 255
PHOENIX AZ
85004-4604
US

IV. Provider business mailing address

656 N 110TH DR
AVONDALE AZ
85323-6717
US

V. Phone/Fax

Practice location:
  • Phone: 602-918-3664
  • Fax:
Mailing address:
  • Phone: 708-980-6894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLAC22766
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: