Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | PSY6491 | CA |
Y | 103TC0700X | Clinical Psychologist | PSY6491 | CA |
NPI | 1003955311 |
---|---|
Provider Name | Kenneth Raven |
First Address | Thousand Oaks, CA 91361-1003 |
Second Address | Thousand Oaks, CA 91361-1003 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/02/2007 |
Last Update Date | 25/08/2015 |