Provider Demographics
NPI:1346590601
Name:MASTRIANO, DANIELLE N (MSW,BA,LMSW,LADC)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:N
Last Name:MASTRIANO
Suffix:
Gender:F
Credentials:MSW,BA,LMSW,LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 E MAIN ST
Mailing Address - Street 2:4TH FLOOR ADMINISTRATION
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-2310
Mailing Address - Country:US
Mailing Address - Phone:203-574-9000
Mailing Address - Fax:203-574-9006
Practice Address - Street 1:141 E MAIN ST
Practice Address - Street 2:3RD FLOOR HOME BASED SERVICES
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-2310
Practice Address - Country:US
Practice Address - Phone:203-575-0466
Practice Address - Fax:203-574-3315
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000078104100000X
CT1124101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008057354Medicaid
12801295OtherCAQH
CTCAC-6076OtherCONNECTICUT CERTIFICATION BOARD, INC
CTICADC-6076OtherCONNECTICUT CERTIFICATION BOARD, INC.