Provider Demographics
NPI:1720622475
Name:RAVENEL, ELIZABETH HOWE (CA LMFT 131814)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:HOWE
Last Name:RAVENEL
Suffix:
Gender:F
Credentials:CA LMFT 131814
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 EMERALD BAY RD # 189
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6200
Mailing Address - Country:US
Mailing Address - Phone:843-860-0951
Mailing Address - Fax:
Practice Address - Street 1:1512 THUNDERBIRD DR
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-4955
Practice Address - Country:US
Practice Address - Phone:843-860-0951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-05
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104145390200000X
CA131814106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01536011OtherMEDI-CAL