Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | LP1839 | MN |
N | 103T00000X | Psychologist | LP1839 | MN |
N | 1041C0700X | Clinical Social Worker | 6878 | MN |
NPI | 1013054642 |
---|---|
Provider Name | Ms. Kelly Jean Ravenfeather |
First Address | Duluth, MN 55802-2104 |
Second Address | Duluth, MN 55802-2104 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/01/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
21F85RA | BLUECROSS BLUESHIELD (01) | MN |
226395 | MANAGED HEALTH NETWORK (01) | MN |
6235843 | MEDICA, UBH, SELECT CARE (01) | MN |
HP35232 | HEALTHPARTNERS (01) | MN |