MEDICARE: STEPHANIE RAVINE PSY.D

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	103TC0700X	Clinical Psychologist	PSY-4372	CO

General Provider Information

NPI Number	:	1518318542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE RAVINE PSY.D

Provider Business Mailing Address
First Line	:	5245 CENTENNIAL BLVD STE 207
Second Line	:
City	:	COLORADO SPGS
State	:	CO
Zip	:	80919-4405
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5245 CENTENNIAL BLVD STE 207
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-4405
Country	:	US
Telephone Number	:	719-357-6471
Fax Number	:

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

Provider Enumeration Date	:	06/30/2016
Last Update Date	:	06/30/2016

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