Healthcare Provider Details

I. General information

NPI: 1487981080
Provider Name (Legal Business Name): REVELATION PILGRIM MENTAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2009
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14932 83RD ST SUITE 100
HOWARD BEACH NY
11414-1207
US

IV. Provider business mailing address

14932 83RD ST SUITE 100
HOWARD BEACH NY
11414-1207
US

V. Phone/Fax

Practice location:
  • Phone: 347-623-2110
  • Fax: 877-278-5969
Mailing address:
  • Phone: 347-623-2110
  • Fax: 877-278-5969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberEXEMPT PRACTITIONER
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License NumberEXEMPT PRACTITIONER
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberEXEMPT PRACTITIONER
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberEXEMPT PRACTITIONER
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberEXEMPT PRACTITIONER
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License NumberEXEMPT PRACTITIONER
License Number StateNY
# 7
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberEXEMPT PRACTITIONER
License Number StateNY
# 8
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberEXEMPT PRACTITIONER
License Number StateNY
# 9
Primary TaxonomyN
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License NumberEXEMPT PRACTITIONER
License Number StateNY
# 10
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberEXEMPT PRACTITIONER
License Number StateNY
# 11
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License NumberEXEMPT PRACTITIONER
License Number StateNY
# 12
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberEXEMPT PRACTITIONER
License Number StateNY
# 13
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberEXEMPT PRACTITIONER
License Number StateNY

VIII. Authorized Official

Name: DR. RAYMOND H RUFEN-BLANCHETTE
Title or Position: PRESIDENT/CEO/DIRECTOR
Credential: DD; PHD
Phone: 347-623-2110