Provider Demographics
NPI:1104271295
Name:HERZOG, RAVEN
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:HERZOG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13256 NE 20TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-2021
Mailing Address - Country:US
Mailing Address - Phone:509-328-2740
Mailing Address - Fax:
Practice Address - Street 1:720 14TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2315
Practice Address - Country:US
Practice Address - Phone:360-423-0203
Practice Address - Fax:360-577-0269
Is Sole Proprietor?:No
Enumeration Date:2016-04-26
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst