Provider Demographics
NPI:1043043490
Name:SMITH, RAVEN
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:SMITH
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 1:5113 S HARPER AVE STE 2C
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4119
Mailing Address - Country:US
Mailing Address - Phone:773-449-0859
Mailing Address - Fax:708-398-8155
Practice Address - Street 1:9115 S CICERO AVE STE 200
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-1771
Practice Address - Country:US
Practice Address - Phone:773-449-0859
Practice Address - Fax:708-398-8155
Is Sole Proprietor?:No
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No374U00000XNursing Service Related ProvidersHome Health Aide