Provider Demographics
NPI:1982895892
Name:RAVENEL, KELLY L (MA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:RAVENEL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 SOLANO AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-1853
Mailing Address - Country:US
Mailing Address - Phone:510-859-3383
Mailing Address - Fax:
Practice Address - Street 1:1350 SOLANO AVE UNIT A
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94706-1853
Practice Address - Country:US
Practice Address - Phone:510-859-3383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51349106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist