Provider Demographics
NPI:1265290076
Name:RAVENELL-CARR, REGINA
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:RAVENELL-CARR
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 1:162 CONKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:WHEATLEY HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11798-1711
Mailing Address - Country:US
Mailing Address - Phone:631-885-4197
Mailing Address - Fax:631-920-6264
Practice Address - Street 1:162 CONKLIN AVE
Practice Address - Street 2:
Practice Address - City:WHEATLEY HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11798-1711
Practice Address - Country:US
Practice Address - Phone:631-885-4197
Practice Address - Fax:631-920-6264
Is Sole Proprietor?:No
Enumeration Date:2024-03-07
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral