Healthcare Provider Details

I. General information

NPI: 1447058466
Provider Name (Legal Business Name): RAVEN MAYSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2025
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 MAPLE AVE
LOS ANGELES CA
90014-2211
US

IV. Provider business mailing address

655 MAPLE AVE
LOS ANGELES CA
90014-2211
US

V. Phone/Fax

Practice location:
  • Phone: 626-378-7694
  • Fax:
Mailing address:
  • Phone: 626-378-7694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: