Provider Demographics
NPI:1710490628
Name:MASSENGALE -HASAN, CAROLYN D (171M00000X)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:D
Last Name:MASSENGALE -HASAN
Suffix:
Gender:F
Credentials:171M00000X
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E 55TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103-1304
Mailing Address - Country:US
Mailing Address - Phone:216-369-8550
Mailing Address - Fax:
Practice Address - Street 1:1400 E 55TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-1304
Practice Address - Country:US
Practice Address - Phone:216-369-8550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-14
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH190703101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)