Provider Demographics
NPI:1689038085
Name:INTRAVAIA, ERIC JOHN (MS)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:JOHN
Last Name:INTRAVAIA
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2717 SEVILLE BLVD
Mailing Address - Street 2:15107
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33764-1163
Mailing Address - Country:US
Mailing Address - Phone:727-507-1956
Mailing Address - Fax:
Practice Address - Street 1:2717 SEVILLE BLVD
Practice Address - Street 2:15107
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764-1163
Practice Address - Country:US
Practice Address - Phone:727-507-1956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 14529101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health