Provider Demographics
NPI:1801606306
Name:RAVENELL, SHAKEEMA
Entity type:Individual
Prefix:
First Name:SHAKEEMA
Middle Name:
Last Name:RAVENELL
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 1:1017 ARNETT BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14619-1433
Mailing Address - Country:US
Mailing Address - Phone:585-944-8286
Mailing Address - Fax:
Practice Address - Street 1:79 N CLINTON AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14604-1407
Practice Address - Country:US
Practice Address - Phone:585-546-7220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY125470104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker