Provider Demographics
NPI:1215296439
Name:RAVENEL, TYESHIA MONIQUE
Entity type:Individual
Prefix:MISS
First Name:TYESHIA
Middle Name:MONIQUE
Last Name:RAVENEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 PARKER ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON CENTER
Mailing Address - State:MA
Mailing Address - Zip Code:02459-2547
Mailing Address - Country:US
Mailing Address - Phone:857-204-2638
Mailing Address - Fax:
Practice Address - Street 1:695 TRUMAN HWY
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:MA
Practice Address - Zip Code:02136-3552
Practice Address - Country:US
Practice Address - Phone:888-763-7272
Practice Address - Fax:877-243-2959
Is Sole Proprietor?:No
Enumeration Date:2012-05-08
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101Y00000XBehavioral Health & Social Service ProvidersCounselor