Provider Demographics
NPI:1629466982
Name:PERONA-FASSI, KARINA
Entity Type:Individual
Prefix:
First Name:KARINA
Middle Name:
Last Name:PERONA-FASSI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3104
Mailing Address - Country:US
Mailing Address - Phone:508-232-6670
Mailing Address - Fax:
Practice Address - Street 1:142 CRESCENT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3104
Practice Address - Country:US
Practice Address - Phone:508-232-6670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1307576Medicaid
MA1303295Medicaid
MAM18463OtherBLUE CROSS BLUE SHIELD
MA1307576Medicaid