Provider Demographics
NPI:1578084935
Name:RODRIGUEZ RAVELO, YANISVELY
Entity Type:Individual
Prefix:
First Name:YANISVELY
Middle Name:
Last Name:RODRIGUEZ RAVELO
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 1:46 IROQUOIS TRL
Mailing Address - Street 2:
Mailing Address - City:RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:11961-1832
Mailing Address - Country:US
Mailing Address - Phone:786-474-7815
Mailing Address - Fax:786-474-7815
Practice Address - Street 1:46 IROQUOIS TRL
Practice Address - Street 2:
Practice Address - City:RIDGE
Practice Address - State:NY
Practice Address - Zip Code:11961-1832
Practice Address - Country:US
Practice Address - Phone:786-474-7815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-06
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-21-57130103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021577000Medicaid
FL1578084935Medicaid
FLR362960905840Medicaid