Healthcare Provider Details

I. General information

NPI: 1003500182
Provider Name (Legal Business Name): RAVEN HEADEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2023
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9025 NOVANT HEALTH PKWY STE 100
CHARLOTTE NC
28227
US

IV. Provider business mailing address

9025 NOVANT HEALTH PKWY STE 100
CHARLOTTE NC
28227
US

V. Phone/Fax

Practice location:
  • Phone: 980-785-1113
  • Fax: 980-785-1114
Mailing address:
  • Phone: 980-785-1113
  • Fax: 980-785-1114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-87781
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: