Basic Information
| Provider Information | |||||||||
| NPI: | 1477751006 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOMERVILLE | ||||||||
| FirstName: | RUAN | ||||||||
| MiddleName: | DAVINA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RAMNARINE | ||||||||
| OtherFirstName: | RUAN | ||||||||
| OtherMiddleName: | DAVINA | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 40 TENEYCK AVE | ||||||||
| Address2: | |||||||||
| City: | VALLEY STREAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115804016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162847994 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6200 BEACH CHANNEL DRIVE | ||||||||
| Address2: | |||||||||
| City: | ARVERNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189457150 | ||||||||
| FaxNumber: | 7186344838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2007 | ||||||||
| LastUpdateDate: | 04/12/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 071513 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 00990152 | 05 | NY | MEDICAID |