Provider Demographics
NPI:1376085043
Name:VALANZOLA, JUSTIN (MED, LABA, BCBA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:VALANZOLA
Suffix:
Gender:M
Credentials:MED, LABA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 643
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02048-0643
Mailing Address - Country:US
Mailing Address - Phone:774-219-7398
Mailing Address - Fax:
Practice Address - Street 1:101 PLAIN ST
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:MA
Practice Address - Zip Code:02766-2907
Practice Address - Country:US
Practice Address - Phone:774-219-7398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-13
Last Update Date:2016-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1399103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1399Medicaid