Basic Information
Provider Information | |||||||||
NPI: | 1497973036 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DE MASO | ||||||||
FirstName: | DANA | ||||||||
MiddleName: | LOUISE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2336 GODDARD PKWY | ||||||||
Address2: |   | ||||||||
City: | SALISBURY | ||||||||
State: | MD | ||||||||
PostalCode: | 218011126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4103346961 | ||||||||
FaxNumber: | 4103346362 | ||||||||
Practice Location | |||||||||
Address1: | 421 PEAR TREE POINT RD | ||||||||
Address2: |   | ||||||||
City: | CHESTERTOWN | ||||||||
State: | MD | ||||||||
PostalCode: | 216202342 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4259224063 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/20/2007 | ||||||||
LastUpdateDate: | 09/21/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LH00007347 | WA | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC2200X | 04716 | MD | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103K00000X | 04716 | MD | N |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   | 103TC0700X | 04716 | MD | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
ID | Type | State | Issuer | Description | 609550002 | 05 | MD |   | MEDICAID | R968 | 01 | MD | CAREFIRST | OTHER | 346646 | 01 | MD | MHN/TRICARE | OTHER | 609550005 | 05 | MD |   | MEDICAID |