Provider Demographics
NPI:1770999021
Name:MASSARI, STACEY (LCSW)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MASSARI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:HILTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:201 E GREEN ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5635
Mailing Address - Country:US
Mailing Address - Phone:607-274-6200
Mailing Address - Fax:607-274-6224
Practice Address - Street 1:201 E GREEN ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5635
Practice Address - Country:US
Practice Address - Phone:607-274-6200
Practice Address - Fax:607-274-6224
Is Sole Proprietor?:No
Enumeration Date:2014-07-08
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY090795104100000X
NY086040-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY090795Medicaid