Provider Demographics
NPI:1073032702
Name:RAVENELLE, GRACE PEARL
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:PEARL
Last Name:RAVENELLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4773 CAUGHLIN PKWY STE 2
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89519-1012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4773 CAUGHLIN PKWY
Practice Address - Street 2:STE 2
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89519
Practice Address - Country:US
Practice Address - Phone:775-677-2216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health