Provider Demographics
NPI:1568556082
Name:MASSONG, STEFAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEFAN
Middle Name:
Last Name:MASSONG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2472 PASS RD
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-2838
Mailing Address - Country:US
Mailing Address - Phone:228-388-9303
Mailing Address - Fax:228-388-9306
Practice Address - Street 1:2472 PASS RD
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2838
Practice Address - Country:US
Practice Address - Phone:228-388-9303
Practice Address - Fax:228-388-9306
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS35-579103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS11428838WOtherCAQH
MS00121755Medicaid
MS60000202Medicare ID - Type Unspecified
MSR56913Medicare UPIN