Provider Demographics
NPI:1760865190
Name:SHAVERS, RAVEN MARIAH (MHRS)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:MARIAH
Last Name:SHAVERS
Suffix:
Gender:F
Credentials:MHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 WALNUT ST APT 6
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94619-3246
Mailing Address - Country:US
Mailing Address - Phone:209-471-8903
Mailing Address - Fax:415-861-0257
Practice Address - Street 1:700 ADELINE ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-2608
Practice Address - Country:US
Practice Address - Phone:510-496-5533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-02
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator