Provider Demographics
NPI:1043826100
Name:GREENWOOD, RAVEN DESTINY
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:DESTINY
Last Name:GREENWOOD
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 1:182 W CEDAR CIR UNIT 31
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525-7812
Mailing Address - Country:US
Mailing Address - Phone:580-378-2411
Mailing Address - Fax:
Practice Address - Street 1:321 E COURT ST
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525-2047
Practice Address - Country:US
Practice Address - Phone:580-889-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator