Provider Demographics
NPI:1578046496
Name:VASSALLO, MADELYNN (MSW,MPH)
Entity Type:Individual
Prefix:
First Name:MADELYNN
Middle Name:
Last Name:VASSALLO
Suffix:
Gender:F
Credentials:MSW,MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 COUNTY RD
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:NH
Mailing Address - Zip Code:03257-5736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:273 COUNTY RD
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:NH
Practice Address - Zip Code:03257-5736
Practice Address - Country:US
Practice Address - Phone:603-526-5425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-07
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1022659104100000X
NH2267104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty