Provider Demographics
NPI:1548925654
Name:FASSAS, DEMETRIUS ALEXANDER (CBHPSS)
Entity type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:ALEXANDER
Last Name:FASSAS
Suffix:
Gender:M
Credentials:CBHPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 N EXCELSIOR AVE
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-8715
Mailing Address - Country:US
Mailing Address - Phone:859-200-6861
Mailing Address - Fax:
Practice Address - Street 1:609 W GALENA ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-1507
Practice Address - Country:US
Practice Address - Phone:406-640-8069
Practice Address - Fax:406-303-5264
Is Sole Proprietor?:No
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-BHPS-CRT-44134175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTBBH-BHPS-CRT-44134OtherBOARD OF BEHAVIORAL HEALTH, CERTIFIED PEER SUPPORT SPECIALIST LICENSE #