Basic Information
| Provider Information | |||||||||
| NPI: | 1477760775 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAZZOLA | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PH.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 JEFFERSON ST. | ||||||||
| Address2: | SUITE 2C | ||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173790496 | ||||||||
| FaxNumber: | 6178070958 | ||||||||
| Practice Location | |||||||||
| Address1: | 872 MASSACHUSETTS AVE. | ||||||||
| Address2: | STE. 2-2, 2-7 | ||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173955806 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 03/03/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | 9890 | MA | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.