MEDICARE: DEMETRIUS ALEXANDER FASSAS CBHPSS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist	BBH-BHPS-CRT-44134	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BBH-BHPS-CRT-44134	OTHER	MT	BOARD OF BEHAVIORAL HEALTH, CERTIFIED PEER SUPPORT SPECIALIST LICENSE #

General Provider Information

NPI Number	:	1548925654
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEMETRIUS ALEXANDER FASSAS CBHPSS

Provider Business Mailing Address
First Line	:	521 N EXCELSIOR AVE
Second Line	:
City	:	BUTTE
State	:	MT
Zip	:	59701-8715
Country	:	US
Telephone Number	:	859-200-6861
Fax Number	:

Provider Business Practice Location Address
First Line	:	609 W GALENA ST
Second Line	:
City	:	BUTTE
State	:	MT
Zip	:	59701-1507
Country	:	US
Telephone Number	:	406-640-8069
Fax Number	:	406-303-5264

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/03/2021
Last Update Date	:	11/03/2021

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