Provider Demographics
NPI:1114081460
Name:MASTO, DIANNA GRACE (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:GRACE
Last Name:MASTO
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:PO BOX 645
Mailing Address - Street 2:
Mailing Address - City:HAGUE
Mailing Address - State:NY
Mailing Address - Zip Code:12836-0645
Mailing Address - Country:US
Mailing Address - Phone:518-817-9267
Mailing Address - Fax:
Practice Address - Street 1:44 ARCADY DRIVE
Practice Address - Street 2:
Practice Address - City:HAGUE
Practice Address - State:NY
Practice Address - Zip Code:12836-0645
Practice Address - Country:US
Practice Address - Phone:518-817-9267
Practice Address - Fax:518-478-9620
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR028591-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000411397001OtherBLUE SHIELD OF NENY PRO #
NY546490OtherVALUEOPTIONS PIN
NY7350232OtherGHI PIN