Provider Demographics
NPI:1578261210
Name:RAEKE, KENDI EM (LGPC)
Entity Type:Individual
Prefix:MRS
First Name:KENDI
Middle Name:EM
Last Name:RAEKE
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 LENWOOD PARK
Mailing Address - Street 2:
Mailing Address - City:SHIPPENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17257-8841
Mailing Address - Country:US
Mailing Address - Phone:717-991-8954
Mailing Address - Fax:
Practice Address - Street 1:13215 BROOK LANE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742
Practice Address - Country:US
Practice Address - Phone:301-733-0330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP131248101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD15859162Medicaid