Healthcare Provider Details

I. General information

NPI: 1316865462
Provider Name (Legal Business Name): RAVEH20 PSYCHIATRIC & MEDICAL SPECIALIST INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 MULKEY RD STE 200
AUSTELL GA
30106-1364
US

IV. Provider business mailing address

1680 MULKEY RD STE 200
AUSTELL GA
30106-1364
US

V. Phone/Fax

Practice location:
  • Phone: 678-744-2318
  • Fax: 770-819-6826
Mailing address:
  • Phone: 678-744-2318
  • Fax: 770-819-6826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: SHELBY DAVIS
Title or Position: CEO
Credential:
Phone: 678-744-2318