Provider Demographics
NPI:1992376123
Name:RAVAGO, THERESA PATRICE LOPEZ
Entity type:Individual
Prefix:
First Name:THERESA PATRICE
Middle Name:LOPEZ
Last Name:RAVAGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THERESA PATRICE
Other - Middle Name:RAVAGO
Other - Last Name:MIRELES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2505 HAZELWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-1309
Mailing Address - Country:US
Mailing Address - Phone:209-337-8227
Mailing Address - Fax:
Practice Address - Street 1:2923 WEBSTER ST STE 201
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3418
Practice Address - Country:US
Practice Address - Phone:510-752-8330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist