Provider Demographics
NPI:1255923793
Name:REDWINE, RAMA (MSW STUDENT INTERN)
Entity type:Individual
Prefix:
First Name:RAMA
Middle Name:
Last Name:REDWINE
Suffix:
Gender:M
Credentials:MSW STUDENT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3910 MONTEREY RD
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-2423
Mailing Address - Country:US
Mailing Address - Phone:808-227-7309
Mailing Address - Fax:
Practice Address - Street 1:1255 KENDALL RD
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-8750
Practice Address - Country:US
Practice Address - Phone:805-503-6206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X
CAASW1230311041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA390200000XMedicaid