Provider Demographics
NPI:1346729605
Name:RAVINE, TITO (CASE MANAGER)
Entity type:Individual
Prefix:
First Name:TITO
Middle Name:
Last Name:RAVINE
Suffix:
Gender:
Credentials:CASE MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 MUSEUM RD
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-4739
Mailing Address - Country:US
Mailing Address - Phone:501-358-6535
Mailing Address - Fax:501-358-6536
Practice Address - Street 1:1301 MUSEUM RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-4739
Practice Address - Country:US
Practice Address - Phone:501-358-6535
Practice Address - Fax:501-358-6536
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARRBT-23-293969106S00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician