=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609069921
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN RAVEN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2007
-----------------------------------------------------
Last Update Date | 12/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2505 SE 11TH AVE STE 332
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97202-1063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-206-9696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10951 SE STEVENS WAY
-----------------------------------------------------
City | HAPPY VALLEY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97086-7435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-206-9696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | C3475
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 10-12-70
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------