Provider Demographics
NPI:1508409087
Name:BARRAVECCHIO, CAROLYN
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:BARRAVECCHIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:GLASGOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:35 SOUTH KENNEDY DRIVE
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720
Mailing Address - Country:US
Mailing Address - Phone:631-696-0972
Mailing Address - Fax:
Practice Address - Street 1:35 SOUTH KENNEDY DRIVE
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720
Practice Address - Country:US
Practice Address - Phone:631-696-0972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist