Basic Information
| Provider Information | |||||||||
| NPI: | 1346590601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASTRIANO | ||||||||
| FirstName: | DANIELLE | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MSW,BA,LMSW,LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | 4TH FLOOR ADMINISTRATION | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | 3RD FLOOR HOME BASED SERVICES | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035750466 | ||||||||
| FaxNumber: | 2035743315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2012 | ||||||||
| LastUpdateDate: | 11/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 000078 | CT | N | Behavioral Health & Social Service Providers | Social Worker | 101YA0400X | 1124 | CT | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 008057354 | 05 | CT | MEDICAID | 12801295 | 01 | CAQH | OTHER | CAC-6076 | 01 | CT | CONNECTICUT CERTIFICATION BOARD, INC | OTHER | ICADC-6076 | 01 | CT | CONNECTICUT CERTIFICATION BOARD, INC. | OTHER |