Provider Demographics
NPI:1740435494
Name:RAVILLE, MINDY SUE (M A, CCC-SLP)
Entity type:Individual
Prefix:MISS
First Name:MINDY
Middle Name:SUE
Last Name:RAVILLE
Suffix:
Gender:F
Credentials:M A, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2155 ROUTE 22B
Mailing Address - Street 2:
Mailing Address - City:MORRISONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12962-3417
Mailing Address - Country:US
Mailing Address - Phone:518-562-3847
Mailing Address - Fax:
Practice Address - Street 1:2155 ROUTE 22B
Practice Address - Street 2:
Practice Address - City:MORRISONVILLE
Practice Address - State:NY
Practice Address - Zip Code:12962-3417
Practice Address - Country:US
Practice Address - Phone:518-562-3847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-21
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016607235Z00000X
NY1826963235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist