Healthcare Provider Details

I. General information

NPI: 1801606306
Provider Name (Legal Business Name): SHAKEEMA RAVENELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2025
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 N CLINTON AVE
ROCHESTER NY
14604-1407
US

IV. Provider business mailing address

1017 ARNETT BLVD
ROCHESTER NY
14619-1433
US

V. Phone/Fax

Practice location:
  • Phone: 585-546-7220
  • Fax:
Mailing address:
  • Phone: 585-944-8286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number125470
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: