=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669425914
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTIAN NICHOLAS CAPUTO LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2006
-----------------------------------------------------
Last Update Date | 01/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 619 ROANOKE AVE
-----------------------------------------------------
City | RIVERHEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11901-2727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-369-1718
-----------------------------------------------------
Fax | 631-874-8618
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 166 HAMPTON VISTA DR
-----------------------------------------------------
City | MANORVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11949-2861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-369-1718
-----------------------------------------------------
Fax | 631-874-8618
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | RP003027-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------