Provider Demographics
NPI:1639568009
Name:RAVENEL, TIFFANY D (MED)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:D
Last Name:RAVENEL
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4179 DAVISON RD
Mailing Address - Street 2:
Mailing Address - City:RAVENEL
Mailing Address - State:SC
Mailing Address - Zip Code:29470-5307
Mailing Address - Country:US
Mailing Address - Phone:843-408-3214
Mailing Address - Fax:843-737-5264
Practice Address - Street 1:2810 ASHLEY PHOSPHATE RD STE B13
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-6401
Practice Address - Country:US
Practice Address - Phone:843-408-3214
Practice Address - Fax:843-737-5264
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5992101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor