Provider Demographics
NPI:1447680574
Name:RIZZOLO, GREGORY SCOTT (MA)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:SCOTT
Last Name:RIZZOLO
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 SOUTH MICHIGAN AVENUE
Mailing Address - Street 2:#1450
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:312-588-0654
Mailing Address - Fax:
Practice Address - Street 1:122 SOUTH MICHIGAN AVENUE
Practice Address - Street 2:#1450
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603
Practice Address - Country:US
Practice Address - Phone:312-588-0654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-27
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178007901101YP2500X
IL180008936101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional