Provider Demographics
NPI:1033457163
Name:SASHA D FASSETT LICENSED CLINICAL SOCIAL WORKER PC
Entity Type:Organization
Organization Name:SASHA D FASSETT LICENSED CLINICAL SOCIAL WORKER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:SASHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:FASSETT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:607-237-5411
Mailing Address - Street 1:217 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760-5244
Mailing Address - Country:US
Mailing Address - Phone:607-237-5411
Mailing Address - Fax:
Practice Address - Street 1:217 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:ENDICOTT
Practice Address - State:NY
Practice Address - Zip Code:13760-5244
Practice Address - Country:US
Practice Address - Phone:607-237-5411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR069367-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1114949062Medicare UPIN