MEDICARE: RAVON ANDERSON LCSWC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	23288	MD

General Provider Information

NPI Number	:	1104691641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAVON ANDERSON LCSWC

Provider Business Mailing Address
First Line	:	4304 FERNHILL AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21215-4830
Country	:	US
Telephone Number	:	443-527-2399
Fax Number	:

Provider Business Practice Location Address
First Line	:	4304 FERNHILL AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21215-4830
Country	:	US
Telephone Number	:	443-527-2399
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2023
Last Update Date	:	11/15/2023

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