Provider Demographics
NPI:1083479505
Name:VASSALLO, KRISTINA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:
Last Name:VASSALLO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700-76 BROADWAY
Mailing Address - Street 2:#172
Mailing Address - City:WESTWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07675
Mailing Address - Country:US
Mailing Address - Phone:914-391-0221
Mailing Address - Fax:
Practice Address - Street 1:372 KINDERKAMACK RD STE 4
Practice Address - Street 2:
Practice Address - City:WESTWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07675-1657
Practice Address - Country:US
Practice Address - Phone:914-391-0221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC051561001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical