Basic Information
| Provider Information | |||||||||
| NPI: | 1508355710 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAVE | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | RAVE | ||||||||
| OtherFirstName: | KIMMY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 625 DELAWARE AVE STE 204 | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142021007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168823151 | ||||||||
| FaxNumber: | 7168864002 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 DELAWARE AVE STE 204 | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142021007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168823151 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2018 | ||||||||
| LastUpdateDate: | 01/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.