Provider Demographics
NPI:1144974841
Name:MASSAGE BY RAVEN (MOBILE, CLINICAL, MASSAGE)
Entity type:Organization
Organization Name:MASSAGE BY RAVEN (MOBILE, CLINICAL, MASSAGE)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MASSAGE THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:757-453-5513
Mailing Address - Street 1:732 EDEN WAY N STE E
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-2798
Mailing Address - Country:US
Mailing Address - Phone:757-453-5513
Mailing Address - Fax:
Practice Address - Street 1:732 EDEN WAY NORTH SUITE E
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-2798
Practice Address - Country:US
Practice Address - Phone:757-453-5513
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0019011535Medicaid
VA0019011535OtherCLINICAL MASSAGE THERAPIST