Provider Demographics
NPI:1811551229
Name:MASTROIANNI, CYAN SKYE
Entity Type:Individual
Prefix:
First Name:CYAN
Middle Name:SKYE
Last Name:MASTROIANNI
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 1:165 VILLA ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-7708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:132 ROBBS HILL RD
Practice Address - Street 2:
Practice Address - City:LUNENBURG
Practice Address - State:MA
Practice Address - Zip Code:01462-2167
Practice Address - Country:US
Practice Address - Phone:774-270-1766
Practice Address - Fax:508-861-0206
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2020-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician