Basic Information
| Provider Information | |||||||||
| NPI: | 1336527415 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASSURA | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | EILEEN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N ACADEMY AVE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178224903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702716144 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 190 WELLES ST., STE. 122 | ||||||||
| Address2: | |||||||||
| City: | FORTY FORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187043856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5707184140 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2015 | ||||||||
| LastUpdateDate: | 08/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PS018338 | PA | Y | Behavioral Health & Social Service Providers | Psychologist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.