Healthcare Provider Details

I. General information

NPI: 1861636391
Provider Name (Legal Business Name): MOYOSORE PAUPAU, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 04/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 CANAL ST
STAMFORD CT
06902-6953
US

IV. Provider business mailing address

39 GLENBROOK RD 5Z
STAMFORD CT
06902-2968
US

V. Phone/Fax

Practice location:
  • Phone: 203-496-2074
  • Fax: 203-355-2667
Mailing address:
  • Phone: 203-496-2074
  • Fax: 203-355-2667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number006466
License Number StateCT

VIII. Authorized Official

Name: MRS. MOYSORE PAUPAU-MICKENS
Title or Position: OWNER
Credential: LCSW
Phone: 203-496-2074