Healthcare Provider Details

I. General information

NPI: 1568933588
Provider Name (Legal Business Name): JANIS SUSAN DIMONACO LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 HAMDEN ST
SPRINGFIELD MA
11937
US

IV. Provider business mailing address

181 COMMODORE DR
JUPITER FL
33477-4007
US

V. Phone/Fax

Practice location:
  • Phone: 413-732-9183
  • Fax:
Mailing address:
  • Phone: 714-803-0284
  • Fax: 561-847-2914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number100-909
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number100909-SW-LICSW
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number909
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: