Provider Demographics
NPI:1265275135
Name:DUBUISSON, HALLIE STAMENTIA
Entity type:Individual
Prefix:
First Name:HALLIE
Middle Name:STAMENTIA
Last Name:DUBUISSON
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 1:19 W CHESTNUT STREET
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301
Mailing Address - Country:US
Mailing Address - Phone:774-339-9643
Mailing Address - Fax:
Practice Address - Street 1:19 W CHESTNUT STREET
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:774-339-9643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2024-06-27
Deactivation Date:2024-06-17
Deactivation Code:
Reactivation Date:2024-06-27
Provider Licenses
StateLicense IDTaxonomies
MASA0720273106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician