Provider Demographics
NPI:1871061630
Name:RAVEN, STEPHANIE (ND)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:RAVEN
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 S 3RD ST W
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-2524
Mailing Address - Country:US
Mailing Address - Phone:406-493-0075
Mailing Address - Fax:888-241-2059
Practice Address - Street 1:206 S 3RD ST W
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-2524
Practice Address - Country:US
Practice Address - Phone:406-493-0075
Practice Address - Fax:888-241-2059
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTAHC-NAT-LIC-1945175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTAHC-NAT-LIC-1945OtherLICENSE
MR5126075OtherDEA