Provider Demographics
NPI:1598202830
Name:MASTRIANNO, MARISA (LPC)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:MASTRIANNO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 MAIN ST S
Mailing Address - Street 2:APARTMENT B
Mailing Address - City:BETHLEHEM
Mailing Address - State:CT
Mailing Address - Zip Code:06751-2030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:82 MAIN ST S
Practice Address - Street 2:APARTMENT B
Practice Address - City:BETHLEHEM
Practice Address - State:CT
Practice Address - Zip Code:06751-2030
Practice Address - Country:US
Practice Address - Phone:860-488-8146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002938101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional