Provider Demographics
NPI:1477760775
Name:GAZZOLA, RYAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:GAZZOLA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 JEFFERSON ST.
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24504
Mailing Address - Country:US
Mailing Address - Phone:617-379-0496
Mailing Address - Fax:617-807-0958
Practice Address - Street 1:872 MASSACHUSETTS AVE.
Practice Address - Street 2:STE. 2-2, 2-7
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139
Practice Address - Country:US
Practice Address - Phone:617-395-5806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
MA9890103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist