Provider Demographics
NPI:1700601549
Name:TATE, RAVYN
Entity type:Individual
Prefix:
First Name:RAVYN
Middle Name:
Last Name:TATE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 N PLEASANT DR
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32435-8696
Mailing Address - Country:US
Mailing Address - Phone:850-401-2686
Mailing Address - Fax:
Practice Address - Street 1:40 STATE HIGHWAY 83
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32433-7404
Practice Address - Country:US
Practice Address - Phone:850-585-9189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty