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General NPI Number Information
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NPI Number | 1134815723
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Entity Type | Individual
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Provider Name | KELLIE ANN MASTROGIOVANNI LBA
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Gender | Female
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Dates
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Enumeration Date | 04/17/2023
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Last Update Date | 03/28/2025
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Provider Practice Location Address
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Address Line | 276 HIGHLAND AVE
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City | WATERBURY
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State | CT
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Zip | 06708-3022
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Country | US
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Telephone | 475-414-5800
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Fax |
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Provider Business Mailing Address
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Address Line | 263 LAUREL HILL RD APT 8
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City | TORRINGTON
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State | CT
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Zip | 06790-5714
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Country | US
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Telephone | 860-459-9717
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 2075
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License Number State | CT
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