Provider Demographics
NPI:1104661305
Name:RICHMOND, RAVEN DAWN
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:DAWN
Last Name:RICHMOND
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 1:3661 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-8218
Mailing Address - Country:US
Mailing Address - Phone:239-245-8761
Mailing Address - Fax:239-689-8694
Practice Address - Street 1:3661 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-8218
Practice Address - Country:US
Practice Address - Phone:239-245-8761
Practice Address - Fax:239-689-8694
Is Sole Proprietor?:No
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-357692106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician