Basic Information
| Provider Information | |||||||||
| NPI: | 1700036449 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUELLAR | ||||||||
| FirstName: | RAVEN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH. D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CUELLAR | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 933 BRADBURY DR SE STE 2222 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723120 | ||||||||
| FaxNumber: | 5052728060 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 TUCKER NE MSC09 5030 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052725002 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2008 | ||||||||
| LastUpdateDate: | 08/19/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC0700X | 1373 | NM | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | 1373 | NM | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.