MEDICARE: RAW THERAPY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1306650171
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RAW THERAPY

Provider Business Mailing Address
First Line	:	3984 LAKE MANOR WAY
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349-8226
Country	:	US
Telephone Number	:	954-294-4870
Fax Number	:

Provider Business Practice Location Address
First Line	:	4827 OLD NATIONAL HWY UNIT 2223
Second Line	:
City	:	COLLEGE PARK
State	:	GA
Zip	:	30337-6234
Country	:	US
Telephone Number	:	470-924-1792
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	TEQUILA SEARS
Credential	:	LCSW
Telephone Number	:	954-294-4870

Provider Enumeration Date	:	02/03/2025
Last Update Date	:	02/03/2025

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