Basic Information
| Provider Information | |||||||||
| NPI: | 1689941684 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRASSO | ||||||||
| FirstName: | ROBERTA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 71 HAYNES ST. | ||||||||
| Address2: | MANCHESTER MEMORIAL | ||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060404131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606476827 | ||||||||
| FaxNumber: | 8605333452 | ||||||||
| Practice Location | |||||||||
| Address1: | 71 HAYNES ST. | ||||||||
| Address2: | MANCHESTER MEMORIAL | ||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060404131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606476827 | ||||||||
| FaxNumber: | 8605333452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2011 | ||||||||
| LastUpdateDate: | 12/11/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 001279 | CT | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 004025177 | 05 | CT | MEDICAID |