Provider Demographics
NPI:1992426464
Name:RAVENEAU, NADINE ANN (SLP-CCC/ SLP- CF/ TS)
Entity type:Individual
Prefix:MS
First Name:NADINE
Middle Name:ANN
Last Name:RAVENEAU
Suffix:
Gender:F
Credentials:SLP-CCC/ SLP- CF/ TS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16120 129TH AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-2922
Mailing Address - Country:US
Mailing Address - Phone:917-912-6916
Mailing Address - Fax:
Practice Address - Street 1:622 3RD AVE FL 7
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-6723
Practice Address - Country:US
Practice Address - Phone:212-634-2803
Practice Address - Fax:646-650-5963
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-05
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1646965221390200000X
NY033469-01235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program