Basic Information
| Provider Information | |||||||||
| NPI: | 1811417082 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHARLES-TABACCO | ||||||||
| FirstName: | CASSANDRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 FAIRFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066044252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033946529 | ||||||||
| FaxNumber: | 2036106131 | ||||||||
| Practice Location | |||||||||
| Address1: | 180 FAIRFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066044252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033946529 | ||||||||
| FaxNumber: | 2036106131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 101YP2500X | CT | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 06-0669106 | 05 | CT | MEDICAID |