Provider Demographics
NPI:1033968128
Name:RAVELO OLIVA, JUAN LEONEL
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:LEONEL
Last Name:RAVELO OLIVA
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 1:140 GUNNERY RD S
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33973-2013
Mailing Address - Country:US
Mailing Address - Phone:239-671-7688
Mailing Address - Fax:
Practice Address - Street 1:5339 CENTENNIAL BLVD
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33971-7555
Practice Address - Country:US
Practice Address - Phone:239-671-7688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-343787103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst