Healthcare Provider Details

I. General information

NPI: 1174435036
Provider Name (Legal Business Name): RAVEN RAPHAELLE TOLBERT BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3682V HIGHLANDS PKWY SE
SMYRNA GA
30082-5184
US

IV. Provider business mailing address

18726 S WESTERN AVE
GARDENA CA
90248-3813
US

V. Phone/Fax

Practice location:
  • Phone: 678-394-3614
  • Fax:
Mailing address:
  • Phone: 318-856-0800
  • Fax: 855-568-2494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1574324
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: