Provider Demographics
NPI:1154059103
Name:FOLMAR, RAVEN LYNN
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:LYNN
Last Name:FOLMAR
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 1:415 N RICHARD JACKSON BLVD STE 209
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32407-3694
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 N RICHARD JACKSON BLVD STE 209
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32407-3694
Practice Address - Country:US
Practice Address - Phone:850-866-0441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22-227720106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician