Provider Demographics
NPI:1003909664
Name:ELLIS, RAVEN KETURAH (LCPC)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:KETURAH
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:RAVEN
Other - Middle Name:KETURAH
Other - Last Name:ELLIS-TAYLOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10400 RIDGELAND ROAD STE 1
Mailing Address - Street 2:
Mailing Address - City:COCKEYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21030
Mailing Address - Country:US
Mailing Address - Phone:410-628-6120
Mailing Address - Fax:410-628-9825
Practice Address - Street 1:3525 RESOURCE DRIVE ROOM C47
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133
Practice Address - Country:US
Practice Address - Phone:410-655-7655
Practice Address - Fax:410-655-3941
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC1921101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
251690OtherCOMPSYCH
64558301OtherCAREFIRST MD
R5830050OtherCAREFIRST EHMSI