Provider Demographics
NPI:1124804216
Name:MAXWELL, RAVEN (EDS)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19611 CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23803-3143
Mailing Address - Country:US
Mailing Address - Phone:434-917-0186
Mailing Address - Fax:
Practice Address - Street 1:6410 COURTS DR
Practice Address - Street 2:
Practice Address - City:PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23875-2562
Practice Address - Country:US
Practice Address - Phone:804-733-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPPS-0605938103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool