Provider Demographics
NPI:1194590232
Name:SHAW, RAVEN (BEHAVIOR TECHNICIAN)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:BEHAVIOR TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3809 LAKE EASTBROOK BLVD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-5931
Mailing Address - Country:US
Mailing Address - Phone:616-604-8493
Mailing Address - Fax:
Practice Address - Street 1:3809 LAKE EASTBROOK BLVD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5931
Practice Address - Country:US
Practice Address - Phone:616-604-8492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician