MEDICARE: MS. CARRIE EILEEN MASSURA M.S.

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	103T00000X	Psychologist	PS018338	PA
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1336527415
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CARRIE EILEEN MASSURA M.S.

Provider Business Mailing Address
First Line	:	100 N ACADEMY AVE
Second Line	:
City	:	DANVILLE
State	:	PA
Zip	:	17822-4903
Country	:	US
Telephone Number	:	570-271-6144
Fax Number	:

Provider Business Practice Location Address
First Line	:	190 WELLES ST., STE. 122
Second Line	:
City	:	FORTY FORT
State	:	PA
Zip	:	18704-3856
Country	:	US
Telephone Number	:	570-718-4140
Fax Number	:

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

Provider Enumeration Date	:	05/11/2015
Last Update Date	:	08/28/2020

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