Healthcare Provider Details

I. General information

NPI: 1033284732
Provider Name (Legal Business Name): DOMINICK MASSARO CDC III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 HAMBURG ST ST PETERS ADDICTION RECOVERY CENTER
SCHENECTADY NY
12303-4343
US

IV. Provider business mailing address

2209 FAIRLAWN PKWY
SCHENECTADY NY
12309-2307
US

V. Phone/Fax

Practice location:
  • Phone: 518-357-2909
  • Fax: 518-357-2937
Mailing address:
  • Phone: 518-357-2909
  • Fax: 518-357-2937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: