Provider Demographics
NPI:1114949062
Name:FASSETT, SASHA DORA (LCSW)
Entity Type:Individual
Prefix:
First Name:SASHA
Middle Name:DORA
Last Name:FASSETT
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 1:1040 VESTAL PKWY E
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-1748
Mailing Address - Country:US
Mailing Address - Phone:607-237-5411
Mailing Address - Fax:607-656-5691
Practice Address - Street 1:1040 VESTAL PKWY E
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-1748
Practice Address - Country:US
Practice Address - Phone:607-237-5411
Practice Address - Fax:607-656-5691
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2008-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0693671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYIA1130Medicare PIN