Provider Demographics
NPI:1881939452
Name:DACUNHA, MARTIN (LCSW)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:DACUNHA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-1801
Mailing Address - Country:US
Mailing Address - Phone:631-588-6304
Mailing Address - Fax:
Practice Address - Street 1:38 SMITH ST
Practice Address - Street 2:BLDG 804
Practice Address - City:NIANTIC
Practice Address - State:CT
Practice Address - Zip Code:06037
Practice Address - Country:US
Practice Address - Phone:860-739-9672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-07
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0079001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical