1225435050 NPI number — RAVEN INDIGO WINTER MA, LPCC, CCTP

Table of content: RAVEN INDIGO WINTER MA, LPCC, CCTP (NPI 1225435050)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225435050 NPI number — RAVEN INDIGO WINTER MA, LPCC, CCTP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WINTER
Provider First Name:
RAVEN
Provider Middle Name:
INDIGO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LPCC, CCTP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NELSON
Provider Other First Name:
SHANNON
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1225435050
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2205 MEADOW OAK AVE APT 241
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTICELLO
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55362-2612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
637-639-9801
Provider Business Mailing Address Fax Number:
763-657-0819

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21395 JOHN MILLESS DR STE 400
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROGERS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55374-4407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-424-1888
Provider Business Practice Location Address Fax Number:
763-424-7288
Provider Enumeration Date:
11/21/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 1759 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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