Provider Demographics
NPI:1205073749
Name:RAVIZZA, JASON CHRISTIAN (MED,LMHC)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:CHRISTIAN
Last Name:RAVIZZA
Suffix:
Gender:M
Credentials:MED,LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SILVER ST,
Mailing Address - Street 2:UNIT 106
Mailing Address - City:AGAWAM
Mailing Address - State:MA
Mailing Address - Zip Code:01001
Mailing Address - Country:US
Mailing Address - Phone:413-789-9198
Mailing Address - Fax:413-789-6322
Practice Address - Street 1:200 SILVER ST.
Practice Address - Street 2:(AGAWAM CROSSING) SUITE 106
Practice Address - City:AGAWAM
Practice Address - State:MA
Practice Address - Zip Code:01001
Practice Address - Country:US
Practice Address - Phone:413-789-9198
Practice Address - Fax:413-789-6322
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4027101YM0800X
MA365449101YS0200X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool