Provider Demographics
NPI:1568919041
Name:RAVEAU, HASTI ASHTIANI (MA)
Entity Type:Individual
Prefix:
First Name:HASTI
Middle Name:ASHTIANI
Last Name:RAVEAU
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19202 WINDRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-3919
Mailing Address - Country:US
Mailing Address - Phone:248-605-5402
Mailing Address - Fax:
Practice Address - Street 1:500 E WASHINGTON ST STE 100
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2057
Practice Address - Country:US
Practice Address - Phone:734-764-3471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016221103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical