Healthcare Provider Details

I. General information

NPI: 1831419415
Provider Name (Legal Business Name): MR. JASON CHARLES LAVIOLETTE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2010
Last Update Date: 06/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3086 CRANBERRY HWY
EAST WAREHAM MA
02538-4801
US

IV. Provider business mailing address

40C CARRIAGE DR
NEW BEDFORD MA
02740-1819
US

V. Phone/Fax

Practice location:
  • Phone: 508-295-7990
  • Fax:
Mailing address:
  • Phone: 508-264-1630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: