MEDICARE: LERONNE JEANETTE RAVID

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	IMH 7957	FL

General Provider Information

NPI Number	:	1225330947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LERONNE JEANETTE RAVID

Provider Business Mailing Address
First Line	:	2303 HOLLYWOOD BLVD
Second Line	:	12
City	:	HOLLYWOOD
State	:	FL
Zip	:	33020-6711
Country	:	US
Telephone Number	:	954-923-9111
Fax Number	:	954-923-9190

Provider Business Practice Location Address
First Line	:	2303 HOLLYWOOD BLVD
Second Line	:	12
City	:	HOLLYWOOD
State	:	FL
Zip	:	33020-6711
Country	:	US
Telephone Number	:	954-923-9111
Fax Number	:	954-923-9190

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2010
Last Update Date	:	12/01/2010

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