Provider Demographics
NPI:1487981080
Name:REVELATION PILGRIM MENTAL HEALTH SERVICES
Entity type:Organization
Organization Name:REVELATION PILGRIM MENTAL HEALTH SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:H
Authorized Official - Last Name:RUFEN-BLANCHETTE
Authorized Official - Suffix:
Authorized Official - Credentials:DD; PHD
Authorized Official - Phone:347-623-2110
Mailing Address - Street 1:14932 83RD ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-1207
Mailing Address - Country:US
Mailing Address - Phone:347-623-2110
Mailing Address - Fax:877-278-5969
Practice Address - Street 1:14932 83RD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414-1207
Practice Address - Country:US
Practice Address - Phone:347-623-2110
Practice Address - Fax:877-278-5969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-03
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYEXEMPT PRACTITIONER102L00000X, 103TA0700X, 103TC1900X, 103TC2200X, 103TE1100X, 103TF0000X, 103TF0200X, 103TP0814X, 103TP2701X, 103TR0400X, 103TS0200X, 106H00000X, 101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Multi-Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & SportsGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysisGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty