Healthcare Provider Details

I. General information

NPI: 1952817454
Provider Name (Legal Business Name): RAVENSWOOD COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2017
Last Update Date: 07/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8284 28TH CT NE STE A
LACEY WA
98516-7161
US

IV. Provider business mailing address

2824 28TH CT NE SUITE A
LACEY WA
98516
US

V. Phone/Fax

Practice location:
  • Phone: 360-742-0418
  • Fax:
Mailing address:
  • Phone: 360-742-0418
  • Fax: 360-980-4099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberLF60797974
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberLF60797974
License Number StateWA

VIII. Authorized Official

Name: DAVE BOYD
Title or Position: OWNER
Credential: LMFT
Phone: 360-742-0418