Provider Demographics
NPI:1154812261
Name:WATKINS, RAVEN SAMONE
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:SAMONE
Last Name:WATKINS
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 1:324 STEVENS ENTRY
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-1325
Mailing Address - Country:US
Mailing Address - Phone:678-619-0178
Mailing Address - Fax:678-701-1139
Practice Address - Street 1:2537 OAKLEAF RDG
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-6638
Practice Address - Country:US
Practice Address - Phone:205-499-5837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLPA000313235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist