Healthcare Provider Details

I. General information

NPI: 1578123659
Provider Name (Legal Business Name): KIERSTEN ANNE-MOORE CAPOTORTO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 ELM ST
EAST HAVEN CT
06512-2340
US

IV. Provider business mailing address

350 GEORGE ST
NEW HAVEN CT
06511-6617
US

V. Phone/Fax

Practice location:
  • Phone: 203-843-2772
  • Fax:
Mailing address:
  • Phone: 475-224-1175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14409
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: