Provider Demographics
NPI:1679720908
Name:DUSSAULT, MATTHEW RICHARD
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:RICHARD
Last Name:DUSSAULT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5406
Mailing Address - Country:US
Mailing Address - Phone:508-994-9206
Mailing Address - Fax:
Practice Address - Street 1:1563 N MAIN ST STE 208
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-2983
Practice Address - Country:US
Practice Address - Phone:508-324-1060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health