Healthcare Provider Details

I. General information

NPI: 1497686802
Provider Name (Legal Business Name): RAVEN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2389 OAK MYRTLE LN
WESLEY CHAPEL FL
33544-6328
US

IV. Provider business mailing address

300 INTERNATIONAL PKWY
LAKE MARY FL
32746-5035
US

V. Phone/Fax

Practice location:
  • Phone: 813-862-3743
  • Fax:
Mailing address:
  • Phone: 470-650-8148
  • Fax: 470-650-8148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: