1023174141 NPI number — MS. DOMINIQUE STASSART MSW,LICSW

Table of content: MS. DOMINIQUE STASSART MSW,LICSW (NPI 1023174141)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023174141 NPI number — MS. DOMINIQUE STASSART MSW,LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STASSART
Provider First Name:
DOMINIQUE
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSW,LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023174141
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22 LEONARD AVE
Provider Second Line Business Mailing Address:
#2
Provider Business Mailing Address City Name:
CAMBRIDGE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02139-1020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-784-8163
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 LEONARD AVE
Provider Second Line Business Practice Location Address:
#2
Provider Business Practice Location Address City Name:
CAMBRIDGE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02139-1020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-784-8163
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  110629 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1857673 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P07813 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1036030 . This is a "NETWORK HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 500567 . This is a "VALUE OPTIONS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com