Provider Demographics
NPI:1538435128
Name:BEZALEL, MIA (LCSW)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:BEZALEL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:
Other - Last Name:RAVASIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:4700 WISSAHICKON AVE STE 118
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-4248
Mailing Address - Country:US
Mailing Address - Phone:267-597-3600
Mailing Address - Fax:
Practice Address - Street 1:6120B WOODLAND AVE 2ND FL
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19142-3224
Practice Address - Country:US
Practice Address - Phone:215-727-4721
Practice Address - Fax:267-350-5932
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102694997Medicaid