Basic Information
| Provider Information | |||||||||
| NPI: | 1073609186 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAWE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | LPC, LCAS-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 449 E SAINT PETER ST | ||||||||
| Address2: | |||||||||
| City: | NEW IBERIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705603752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373219204 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 449 E SAINT PETER ST | ||||||||
| Address2: | |||||||||
| City: | NEW IBERIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705603752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373219204 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 05/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 2491-A | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 5338 | NC | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 5338 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 6103656 | 05 | NC | MEDICAID |