Provider Demographics
NPI:1679359970
Name:MASSIMINO, GRACE E (MS ED, NCC)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:E
Last Name:MASSIMINO
Suffix:
Gender:F
Credentials:MS ED, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 E HECTOR STREET
Mailing Address - Street 2:
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428
Mailing Address - Country:US
Mailing Address - Phone:215-666-2048
Mailing Address - Fax:
Practice Address - Street 1:1101 E HECTOR STREET
Practice Address - Street 2:
Practice Address - City:CONSHOHOCKEN
Practice Address - State:PA
Practice Address - Zip Code:19428
Practice Address - Country:US
Practice Address - Phone:215-666-2048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-04
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1428778101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health