Provider Demographics
NPI:1447790787
Name:TASSINARI, KIM M (PHD)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:M
Last Name:TASSINARI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 SAWTOOTH CV
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1446
Mailing Address - Country:US
Mailing Address - Phone:203-313-4313
Mailing Address - Fax:
Practice Address - Street 1:88 SAWTOOTH CV
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1446
Practice Address - Country:US
Practice Address - Phone:203-313-4313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001945101YP2500X
NY015586-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional