Provider Demographics
NPI:1194846360
Name:FASS, VIRGINIA G
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:G
Last Name:FASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 MAIN ST STE 315
Mailing Address - Street 2:PO BOX 370
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-2037
Mailing Address - Country:US
Mailing Address - Phone:814-362-5579
Mailing Address - Fax:814-368-5997
Practice Address - Street 1:2 MAIN ST
Practice Address - Street 2:SUITE 315
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-2035
Practice Address - Country:US
Practice Address - Phone:814-362-5579
Practice Address - Fax:814-368-5997
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS006376L103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent