Provider Demographics
NPI:1023379740
Name:RAVENS, ELEANOR (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELEANOR
Middle Name:
Last Name:RAVENS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 315
Mailing Address - Street 2:
Mailing Address - City:MARCELINE
Mailing Address - State:MO
Mailing Address - Zip Code:64658-0315
Mailing Address - Country:US
Mailing Address - Phone:660-413-4484
Mailing Address - Fax:660-376-3894
Practice Address - Street 1:1530 CLAY ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:MO
Practice Address - Zip Code:64601-2065
Practice Address - Country:US
Practice Address - Phone:660-646-4215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-30
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00735235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist