Provider Demographics
NPI:1154486058
Name:MASSARO, DAVID (FAODP)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:MASSARO
Suffix:
Gender:M
Credentials:FAODP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16082 RIVER RIDGE TRAIL
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:MI
Mailing Address - Zip Code:48451
Mailing Address - Country:US
Mailing Address - Phone:810-735-2829
Mailing Address - Fax:
Practice Address - Street 1:1800 IMLAY CITY RD
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-3208
Practice Address - Country:US
Practice Address - Phone:810-667-0243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)