Healthcare Provider Details

I. General information

NPI: 1063233591
Provider Name (Legal Business Name): CHRISTOPHER GEORGE KACZEGOWICZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1586 COUNTRY CLUB RD
MIDDLETOWN CT
06457-2343
US

IV. Provider business mailing address

1586 COUNTRY CLUB RD
MIDDLETOWN CT
06457-2343
US

V. Phone/Fax

Practice location:
  • Phone: 203-400-5390
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number14966
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number181598
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: