Provider Demographics
NPI:1538794458
Name:CONWELL, RAVEN KATHLEEN
Entity type:Individual
Prefix:MS
First Name:RAVEN
Middle Name:KATHLEEN
Last Name:CONWELL
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 1:1911 15TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-4907
Mailing Address - Country:US
Mailing Address - Phone:205-706-8453
Mailing Address - Fax:
Practice Address - Street 1:701 MONTGOMERY HWY STE 202
Practice Address - Street 2:
Practice Address - City:VESTAVIA HILLS
Practice Address - State:AL
Practice Address - Zip Code:35216-1839
Practice Address - Country:US
Practice Address - Phone:205-916-0123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4251101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional