MEDICARE: KELLY L RAVENEL M.A.

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	106H00000X	Marriage & Family Therapist	51349	CA

General Provider Information

NPI Number	:	1982895892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY L RAVENEL M.A.

Provider Business Mailing Address
First Line	:	1350 SOLANO AVE UNIT A
Second Line	:
City	:	ALBANY
State	:	CA
Zip	:	94706-1853
Country	:	US
Telephone Number	:	510-859-3383
Fax Number	:

Provider Business Practice Location Address
First Line	:	1350 SOLANO AVE UNIT A
Second Line	:
City	:	ALBANY
State	:	CA
Zip	:	94706-1853
Country	:	US
Telephone Number	:	510-859-3383
Fax Number	:

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

Provider Enumeration Date	:	08/06/2007
Last Update Date	:	03/21/2018

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