Provider Demographics
NPI:1124586839
Name:DACOSTA, ASHLEY (LCSW)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:DACOSTA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:
Other - Last Name:BALSANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1460 WILLARD AVE
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-4575
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1460 MERIDEN-WATERBURY TURNPIKE
Practice Address - Street 2:
Practice Address - City:PLANTSVILLE
Practice Address - State:CT
Practice Address - Zip Code:06479
Practice Address - Country:US
Practice Address - Phone:203-733-6228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0099211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty