Provider Demographics
NPI:1033870936
Name:KARAMOURTOPOULOS, CASSANDRA P
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:P
Last Name:KARAMOURTOPOULOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MAIN ST STE G
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-3575
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 MAIN ST
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-3575
Practice Address - Country:US
Practice Address - Phone:978-263-1427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-04
Last Update Date:2024-02-14
Deactivation Date:2024-01-29
Deactivation Code:
Reactivation Date:2024-02-06
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MALABA10000582103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid