Provider Demographics
NPI:1730713413
Name:CERVASIO, DINA (LSW)
Entity type:Individual
Prefix:
First Name:DINA
Middle Name:
Last Name:CERVASIO
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N 5TH ST STE 102
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-2609
Mailing Address - Country:US
Mailing Address - Phone:570-730-4211
Mailing Address - Fax:570-730-4214
Practice Address - Street 1:1300 N 5TH ST STE 102
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-2609
Practice Address - Country:US
Practice Address - Phone:704-245-1005
Practice Address - Fax:570-730-4214
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW134765101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health