=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225435050
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAVEN INDIGO WINTER MA, LPCC, CCTP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2014
-----------------------------------------------------
Last Update Date | 10/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21395 JOHN MILLESS DR STE 400
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55374-4407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-424-1888
-----------------------------------------------------
Fax | 763-424-7288
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2205 MEADOW OAK AVE APT 241
-----------------------------------------------------
City | MONTICELLO
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55362-2612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 637-639-9801
-----------------------------------------------------
Fax | 763-657-0819
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 1759
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------