Provider Demographics
NPI:1497028294
Name:CHIASSON, GENA MARIE (ADVANCED CASAC)
Entity Type:Individual
Prefix:
First Name:GENA
Middle Name:MARIE
Last Name:CHIASSON
Suffix:
Gender:F
Credentials:ADVANCED CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 BEACH ST
Mailing Address - Street 2:
Mailing Address - City:MASSENA
Mailing Address - State:NY
Mailing Address - Zip Code:13662-1247
Mailing Address - Country:US
Mailing Address - Phone:315-705-4288
Mailing Address - Fax:
Practice Address - Street 1:25 DIES ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1306
Practice Address - Country:US
Practice Address - Phone:315-379-0139
Practice Address - Fax:315-379-1004
Is Sole Proprietor?:No
Enumeration Date:2012-02-10
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY21237101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY21237OtherOASAS