Healthcare Provider Details

I. General information

NPI: 1780911347
Provider Name (Legal Business Name): RAVEN COUNSELING AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2009
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8625 GOLF COURSE RD NW STE B2
ALBUQUERQUE NM
87114-5114
US

IV. Provider business mailing address

8625 GOLF COURSE RD NW STE B2
ALBUQUERQUE NM
87114-5114
US

V. Phone/Fax

Practice location:
  • Phone: 505-508-0808
  • Fax: 888-896-8728
Mailing address:
  • Phone: 505-508-0808
  • Fax: 888-896-8728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0100131
License Number StateNM

VIII. Authorized Official

Name: TANYA MEDINA
Title or Position: BILLING & NETWORK
Credential: CPB-COC
Phone: 505-508-0808