Provider Demographics
NPI:1689422677
Name:RAITT, ELY COLE
Entity type:Individual
Prefix:
First Name:ELY
Middle Name:COLE
Last Name:RAITT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3619 N MISSION RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:90031-3136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3619 N MISSION RD
Practice Address - Street 2:
Practice Address - City:LINCOLN HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:90031-3136
Practice Address - Country:US
Practice Address - Phone:213-721-0010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-07
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1508070523106S00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician