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General NPI Number Information
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NPI Number | 1609375617
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Entity Type | Individual
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Provider Name | RAVEN VEGA APC, NCC
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Gender | Female
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Dates
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Enumeration Date | 02/05/2018
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Last Update Date | 07/14/2021
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Provider Practice Location Address
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Address Line | 1708 PEACHTREE ST NW STE 425
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City | ATLANTA
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State | GA
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Zip | 30309-7020
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Country | US
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Telephone | 404-565-4385
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Fax |
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Provider Business Mailing Address
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Address Line | 2500 SHALLOWFORD RD NE APT 4323
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City | ATLANTA
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State | GA
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Zip | 30345-1225
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Country | US
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Telephone | 732-379-1825
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | APC008017
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License Number State | GA
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