Provider Demographics
NPI:1487290664
Name:RAVEN, KIMBERLY (LMT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:RAVEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6059 SHORTLEAF DR
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30297-4135
Mailing Address - Country:US
Mailing Address - Phone:678-871-9854
Mailing Address - Fax:
Practice Address - Street 1:1390 LANIER BLVD. NE SUITE 1409-A
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306
Practice Address - Country:US
Practice Address - Phone:678-871-9854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT001871225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist