Provider Demographics
NPI:1821374349
Name:CASSULLO LACHANCE, MARIE-ALANA
Entity Type:Individual
Prefix:
First Name:MARIE-ALANA
Middle Name:
Last Name:CASSULLO LACHANCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIE-ALANA
Other - Middle Name:
Other - Last Name:CASSULLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC, HBCE
Mailing Address - Street 1:107 CHURCH HILL RD
Mailing Address - Street 2:
Mailing Address - City:SANDY HOOK
Mailing Address - State:CT
Mailing Address - Zip Code:06482-1108
Mailing Address - Country:US
Mailing Address - Phone:203-509-6254
Mailing Address - Fax:
Practice Address - Street 1:107 CHURCH HILL RD
Practice Address - Street 2:
Practice Address - City:SANDY HOOK
Practice Address - State:CT
Practice Address - Zip Code:06482-1108
Practice Address - Country:US
Practice Address - Phone:203-509-6254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-28
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001792101YP2500X
CT0553101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool