Basic Information
| Provider Information | |||||||||
| NPI: | 1003929134 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAVILLE | ||||||||
| FirstName: | MARCIA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | LCSW-R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 COMMERCE LN | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136173739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153868191 | ||||||||
| FaxNumber: | 3153799388 | ||||||||
| Practice Location | |||||||||
| Address1: | 380 COUNTY ROUTE 51 | ||||||||
| Address2: | |||||||||
| City: | MALONE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 129534504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184830109 | ||||||||
| FaxNumber: | 5184830115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 01/09/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | R047843-1 | NY | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 047843 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.