Provider Demographics
NPI:1053188524
Name:ROCKNAK, RAVEN DAYLE
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:DAYLE
Last Name:ROCKNAK
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 1:730 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-1421
Mailing Address - Country:US
Mailing Address - Phone:717-420-0842
Mailing Address - Fax:
Practice Address - Street 1:730 N MONROE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-1421
Practice Address - Country:US
Practice Address - Phone:717-420-0842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician