Provider Demographics
NPI:1649162603
Name:KELLEY, RAVEN
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:KELLEY
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 1:453 MEEKS LOOP
Mailing Address - Street 2:
Mailing Address - City:ADAMSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38310-2531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:453 MEEKS LOOP
Practice Address - Street 2:
Practice Address - City:ADAMSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38310-2531
Practice Address - Country:US
Practice Address - Phone:931-279-9293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-16
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist