Provider Demographics
NPI:1194891028
Name:STONE, MATILDE MASSANA (LCSW)
Entity type:Individual
Prefix:
First Name:MATILDE
Middle Name:MASSANA
Last Name:STONE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 N MOUNT AUBURN RD
Mailing Address - Street 2:SUITE K
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2169
Mailing Address - Country:US
Mailing Address - Phone:573-335-0570
Mailing Address - Fax:573-335-8559
Practice Address - Street 1:1707 N MOUNT AUBURN RD
Practice Address - Street 2:SUITE K
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2169
Practice Address - Country:US
Practice Address - Phone:573-335-0570
Practice Address - Fax:573-335-8559
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0006861041C0700X
FLSW 50841041C0700X
IL149.0062321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO22405OtherBLUE CROSS BLUE SHIELD
MO498251701Medicaid
MO000078505Medicare ID - Type Unspecified