=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316705866
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAVEN MIMS M.S., LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2024
-----------------------------------------------------
Last Update Date | 03/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1605 LONE PINE DR
-----------------------------------------------------
City | LITTLE ELM
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75068-3166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-430-4404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1605 LONE PINE DR
-----------------------------------------------------
City | LITTLE ELM
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75068-3166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-430-4404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 88179
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------