Provider Demographics
NPI:1023174141
Name:STASSART, DOMINIQUE (MSW,LICSW)
Entity type:Individual
Prefix:MS
First Name:DOMINIQUE
Middle Name:
Last Name:STASSART
Suffix:
Gender:F
Credentials:MSW,LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 LEONARD AVE
Mailing Address - Street 2:#2
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-1020
Mailing Address - Country:US
Mailing Address - Phone:617-784-8163
Mailing Address - Fax:
Practice Address - Street 1:22 LEONARD AVE
Practice Address - Street 2:#2
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-1020
Practice Address - Country:US
Practice Address - Phone:617-784-8163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1106291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1857673Medicaid
MAP07813OtherBCBS
MA1036030OtherNETWORK HEALTH
MA500567OtherVALUE OPTIONS
MA1857673Medicaid