Healthcare Provider Details

I. General information

NPI: 1720131212
Provider Name (Legal Business Name): DIANE HUSTON FASSAK L.I.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 WHITING ST SUITE #5
HINGHAM MA
02043-3724
US

IV. Provider business mailing address

210 WHITING ST SUITE #5
HINGHAM MA
02043-3724
US

V. Phone/Fax

Practice location:
  • Phone: 781-740-1188
  • Fax: 508-337-8619
Mailing address:
  • Phone: 781-740-1188
  • Fax: 508-337-8619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number105561
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: