Provider Demographics
NPI:1700036449
Name:CUELLAR, RAVEN ELIZABETH (PH D)
Entity Type:Individual
Prefix:MISS
First Name:RAVEN
Middle Name:ELIZABETH
Last Name:CUELLAR
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:MISS
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:CUELLAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:933 BRADBURY DR SE STE 2222
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4375
Mailing Address - Country:US
Mailing Address - Phone:505-272-3120
Mailing Address - Fax:505-272-8060
Practice Address - Street 1:2400 TUCKER NE MSC09 5030
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-5002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NM1373103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent