Healthcare Provider Details

I. General information

NPI: 1104271295
Provider Name (Legal Business Name): RAVEN HERZOG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2016
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 14TH AVE
LONGVIEW WA
98632-2315
US

IV. Provider business mailing address

13256 NE 20TH ST STE 1
BELLEVUE WA
98005-2021
US

V. Phone/Fax

Practice location:
  • Phone: 360-423-0203
  • Fax: 360-577-0269
Mailing address:
  • Phone: 509-328-2740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: