Provider Demographics
NPI:1003929134
Name:RAVILLE, MARCIA J (LCSW-R)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:J
Last Name:RAVILLE
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 COMMERCE LN
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-3739
Mailing Address - Country:US
Mailing Address - Phone:315-386-8191
Mailing Address - Fax:315-379-9388
Practice Address - Street 1:380 COUNTY ROUTE 51
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-4504
Practice Address - Country:US
Practice Address - Phone:518-483-0109
Practice Address - Fax:518-483-0115
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR047843-11041C0700X
NY0478431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS96186Medicare UPIN
NYBB8471Medicare ID - Type Unspecified