Provider Demographics
NPI:1578698619
Name:RAVITZ, LIZA JILL (LIZA RAVITZ, PHD)
Entity Type:Individual
Prefix:DR
First Name:LIZA
Middle Name:JILL
Last Name:RAVITZ
Suffix:
Gender:F
Credentials:LIZA RAVITZ, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 WESTERN AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-2919
Mailing Address - Country:US
Mailing Address - Phone:707-762-7828
Mailing Address - Fax:707-773-1761
Practice Address - Street 1:318 WESTERN AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2919
Practice Address - Country:US
Practice Address - Phone:707-762-7828
Practice Address - Fax:707-773-1761
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY6295103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist