Healthcare Provider Details

I. General information

NPI: 1033982434
Provider Name (Legal Business Name): RAVEN GENDRON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2023
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5535 CURRITUCK DR STE 220
WILMINGTON NC
28403-1155
US

IV. Provider business mailing address

145 AMARYLLIS DR
WILMINGTON NC
28411-8810
US

V. Phone/Fax

Practice location:
  • Phone: 910-251-8990
  • Fax:
Mailing address:
  • Phone: 828-838-9992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: