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NPI Code Detail

MEDICARE: DR. JONATHAN MICHAEL RAVARINO PHD

MEDICARE: DR. JONATHAN MICHAEL RAVARINO PHD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103T00000XPsychologist5179442-2501UT
21041C0700XClinical Social Worker5179442-3501UT

General Provider Information

NPI Number : 1881926269
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JONATHAN MICHAEL RAVARINO PHD
Provider Business Mailing Address
First Line : 2665 S 1900 E
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84106-4155
Country : US
Telephone Number : 801-918-5275
Fax Number :
Provider Business Practice Location Address
First Line : 201 S 1460 E RM 426
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84112-9061
Country : US
Telephone Number : 801-918-5275
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/09/2010
Last Update Date : 11/02/2010

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