Healthcare Provider Details

I. General information

NPI: 1245463017
Provider Name (Legal Business Name): DAISY RAVELO MENTAL HEALTH PRACTI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2009
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 41ST OCEAN
MARATHON FL
33050-2373
US

IV. Provider business mailing address

4800 OVERSEAS HWY APT 9
MARATHON FL
33050-2639
US

V. Phone/Fax

Practice location:
  • Phone: 305-434-9023
  • Fax: 305-434-9040
Mailing address:
  • Phone: 954-394-2835
  • Fax: 866-610-3757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberITM-406
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: