Provider Demographics
NPI:1689941684
Name:GRASSO, ROBERTA M (LMFT)
Entity Type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:M
Last Name:GRASSO
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 HAYNES ST.
Mailing Address - Street 2:MANCHESTER MEMORIAL
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4131
Mailing Address - Country:US
Mailing Address - Phone:860-647-6827
Mailing Address - Fax:860-533-3452
Practice Address - Street 1:71 HAYNES ST.
Practice Address - Street 2:MANCHESTER MEMORIAL
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4131
Practice Address - Country:US
Practice Address - Phone:860-647-6827
Practice Address - Fax:860-533-3452
Is Sole Proprietor?:No
Enumeration Date:2011-11-19
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001279106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004025177Medicaid