Provider Demographics
NPI:1114632577
Name:RAVEN ROCK WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:RAVEN ROCK WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:606-775-0515
Mailing Address - Street 1:221 HALLS RD
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:KY
Mailing Address - Zip Code:40380-2027
Mailing Address - Country:US
Mailing Address - Phone:606-775-0515
Mailing Address - Fax:606-552-0964
Practice Address - Street 1:221 HALLS RD
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:KY
Practice Address - Zip Code:40380-2027
Practice Address - Country:US
Practice Address - Phone:606-775-0515
Practice Address - Fax:606-552-0964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health