Provider Demographics
NPI:1487196580
Name:VANTASSELL, DOUGLAS A (CASAC-T)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:A
Last Name:VANTASSELL
Suffix:
Gender:M
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 PENFIELD DR
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-4901
Mailing Address - Country:US
Mailing Address - Phone:631-239-5071
Mailing Address - Fax:631-239-5071
Practice Address - Street 1:5 PENFIELD DR
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-4901
Practice Address - Country:US
Practice Address - Phone:631-239-5071
Practice Address - Fax:631-239-5071
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)