Provider Demographics
NPI:1508644121
Name:RAVELO, SOFIA (MED, ALC)
Entity Type:Individual
Prefix:
First Name:SOFIA
Middle Name:
Last Name:RAVELO
Suffix:
Gender:F
Credentials:MED, ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6003 NEILL DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-2523
Mailing Address - Country:US
Mailing Address - Phone:334-224-0556
Mailing Address - Fax:
Practice Address - Street 1:1763 TALIAFERRO TRL
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-7758
Practice Address - Country:US
Practice Address - Phone:334-398-8516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-15
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALALC04537101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health