Healthcare Provider Details

I. General information

NPI: 1538616438
Provider Name (Legal Business Name): RAVEN TRAYLOR LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2434 S EASON BLVD
TUPELO MS
38804-6942
US

IV. Provider business mailing address

2434 S EASON BLVD
TUPELO MS
38804-6942
US

V. Phone/Fax

Practice location:
  • Phone: 662-640-4595
  • Fax: 662-680-6416
Mailing address:
  • Phone: 662-640-4595
  • Fax: 662-680-6416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-11599
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: