Provider Demographics
NPI:1265008825
Name:HADDOCK, RAVEN R
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:R
Last Name:HADDOCK
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 1:280 FORT WASHINGTON AVE APT 33
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1306
Mailing Address - Country:US
Mailing Address - Phone:203-984-8486
Mailing Address - Fax:
Practice Address - Street 1:280 FORT WASHINGTON AVE APT 33
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1306
Practice Address - Country:US
Practice Address - Phone:203-984-8486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty