Provider Demographics
NPI:1710921366
Name:CASSELLA, MARIE A (LICSW)
Entity Type:Individual
Prefix:MS
First Name:MARIE
Middle Name:A
Last Name:CASSELLA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 DORCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122
Mailing Address - Country:US
Mailing Address - Phone:617-825-5000
Mailing Address - Fax:617-288-5991
Practice Address - Street 1:1500 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122
Practice Address - Country:US
Practice Address - Phone:617-825-5000
Practice Address - Fax:617-288-5991
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1020771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0300010Medicaid