Provider Demographics
NPI:1346924016
Name:RAVILLE, ALEXI (CTRS, CADC-DP, QMHP)
Entity Type:Individual
Prefix:
First Name:ALEXI
Middle Name:
Last Name:RAVILLE
Suffix:
Gender:F
Credentials:CTRS, CADC-DP, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N FRONT
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49651-9307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6919 MAPLEWOOD RD
Practice Address - Street 2:
Practice Address - City:INDIAN RIVER
Practice Address - State:MI
Practice Address - Zip Code:49749-9463
Practice Address - Country:US
Practice Address - Phone:231-838-9777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI82945225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist