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General NPI Number Information
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NPI Number | 1679313977
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Entity Type | Individual
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Provider Name | DOMINIQUE RAVIN
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Gender | Female
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Dates
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Enumeration Date | 05/27/2024
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Last Update Date | 05/27/2024
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Provider Practice Location Address
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Address Line | 460 BLOOMFIELD AVE STE OFFICE2
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City | MONTCLAIR
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State | NJ
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Zip | 07042-3582
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Country | US
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Telephone | 732-674-9857
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Fax |
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Provider Business Mailing Address
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Address Line | 97 VIVANTE BLVD # 303
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City | PUNTA GORDA
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State | FL
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Zip | 33950-2025
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Country | US
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Telephone | 732-674-9857
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 37AC00734200
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License Number State |
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