Healthcare Provider Details

I. General information

NPI: 1518506682
Provider Name (Legal Business Name): RAVEN THOMPSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2020
Last Update Date: 10/03/2026
Certification Date: 10/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1123 CLAIRMONT RD
DECATUR GA
30030-1228
US

IV. Provider business mailing address

3939 LAVISTA RD STE E-125
TUCKER GA
30084-5162
US

V. Phone/Fax

Practice location:
  • Phone: 770-316-3008
  • Fax:
Mailing address:
  • Phone: 770-316-3008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW008892
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: