Provider Demographics
NPI:1013054642
Name:RAVENFEATHER, KELLY JEAN (MS ED, LP, LMFT)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:JEAN
Last Name:RAVENFEATHER
Suffix:
Gender:F
Credentials:MS ED, LP, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 E SUPERIOR ST STE 101
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2104
Mailing Address - Country:US
Mailing Address - Phone:218-726-5433
Mailing Address - Fax:218-279-2844
Practice Address - Street 1:230 E SUPERIOR ST STE 101
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2104
Practice Address - Country:US
Practice Address - Phone:218-726-5433
Practice Address - Fax:218-279-2844
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1839103T00000X
MN68781041C0700X
MN497106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP35232OtherHEALTHPARTNERS
MN226395OtherMANAGED HEALTH NETWORK
MN6235843OtherMEDICA, UBH, SELECT CARE
MN21F85RAOtherBLUECROSS BLUESHIELD