Provider Demographics
NPI:1548960222
Name:NEATHERLIN, RAVEN JOESINE
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:JOESINE
Last Name:NEATHERLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RAVEN
Other - Middle Name:JOESINE
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3980 HOLLY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-6366
Mailing Address - Country:US
Mailing Address - Phone:580-516-1835
Mailing Address - Fax:
Practice Address - Street 1:2000 E LINCOLN RD
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-7353
Practice Address - Country:US
Practice Address - Phone:580-286-6639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3604002084B0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & Neuropsychiatry