Provider Demographics
NPI:1225435050
Name:WINTER, RAVEN INDIGO (MA, LPCC, CCTP)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:INDIGO
Last Name:WINTER
Suffix:
Gender:F
Credentials:MA, LPCC, CCTP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:R
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:2205 MEADOW OAK AVE APT 241
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-2612
Mailing Address - Country:US
Mailing Address - Phone:637-639-9801
Mailing Address - Fax:763-657-0819
Practice Address - Street 1:21395 JOHN MILLESS DR STE 400
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-4407
Practice Address - Country:US
Practice Address - Phone:763-424-1888
Practice Address - Fax:763-424-7288
Is Sole Proprietor?:No
Enumeration Date:2014-11-21
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MN1759101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health